PRESCRIPTION DRUG RIDER. Beechcraft

Transcription

1 PRESCRIPTION DRUG RIDER Beechcraft If You have Medicare or will become Eligible for Medicare in the next twelve (12) months, Federal law gives You choices about Your prescription drug coverage. Please see page 5 for more details. This Prescription Drug Rider (Rider) is made a part of the Certificate of Coverage (COC). The benefits provided by this Rider become effective on the date Coverage under the Agreement is effective. Benefit 1 Formulary Tier 1 Prescription Drugs Formulary Tier 2 Prescription Drugs Non-Formulary Tier 3 Prescription Drugs Orally Administered Anti-Cancer Medications Member Responsibility Participating Pharmacy 34 Day Supply Non-Participating Pharmacy Mail Order 90 Day Supply $10 Copayment $10 Copayment 2 times the 34 day designated Member Responsibility $40 Copayment $40 Copayment 2 times the 34 day designated Member Responsibility $80 Copayment $80 Copayment 2 times the 34 day designated Member Responsibility $0 $0 Not Covered 1. To find Your Prescription Drug, its applicable Tier and any Prior Authorization requirements, visit Our searchable Formulary on Our website or by contacting the Customer Service Department. PRESCRIPTION DRUG BENEFITS: Subject to the terms, conditions and scope of Coverage, including all Exclusions, limitations and defined terms of the Agreement unless otherwise provided in this Rider, Member Responsibility and Ancillary Charges, outpatient Prescription Drugs will be Covered as listed below, when: Medically Necessary; You are eligible to receive Covered Services; and The Covered Prescription is written by a Prescribing Provider; included on the Formulary; and filled at a pharmacy. To obtain the maximum benefit, You should present Your ID Card to a Participating Retail Pharmacy. In the event a Covered Prescription is filled at a Non-Participating Pharmacy or a Participating Pharmacy where the ID Card is not shown, You will be reimbursed the Allowed Amount(s) minus the Member Responsibility. You will also be responsible for the difference between the actual billed charges of a Non-Participating Pharmacy and the Allowed 1 underwritten by

2 Amounts. RESTRICTED GENERIC Generically equivalent pharmaceuticals will be dispensed whenever there is an FDA approved Formulary Generic Drug. If You receive a brand name Prescription Drug when a Formulary Generic Drug is available, You will be responsible for the Ancillary Charge and the Tier 2 or Tier 3 Member Responsibility. If the Physician instructs the Pharmacy to Dispense As Written ( DAW ), You will only be responsible for the applicable Tier 2 or Tier 3 Copayment. The total Member Responsibility shall not exceed the total allowable cost of the Prescription Drug. TOBACCO CESSATION DRUG BENEFIT The Covered Prescription must be prescribed to an eligible individual in connection with an approved tobacco cessation program. The Covered Prescription will be prescribed at the discretion of the Your Physician and may have age restrictions associated with it. Coverage will be provided for a 180 day supply of a Covered Prescription Drug for tobacco cessation, through any Participating Mail Order Pharmacy. The list of Covered Prescriptions is subject to change as new tobacco cessation drugs become available and the Plan makes a determination whether such medications are covered or non-covered. Coverage under this section will apply to Covered Prescriptions dispensed at a Participating Mail Order or Retail Pharmacy who agrees in writing to the same terms and conditions that apply to the contractual agreement offered to any Participating Mail Order Pharmacy. The following also apply: Member Responsibility will be charged for each Covered Prescription each time a prescription is filled or refilled, up to a thirty-four (34) day supply for Retail and Specialty Pharmacy, and up to a ninety (90) day supply for Mail Order Pharmacy. You are required to pay the full Member Responsibility to the Participating Pharmacy at the time the prescription is obtained. In the event that the Covered Prescription cost is less than the Member Responsibility, You will be responsible for the cost of the Covered Prescription. Controlled Substance Prescriptions and non-maintenance Medications are not covered through a Mail Order Pharmacy. Coverage for preventive drug products will be provided at 100% of Allowed Amounts in a manner consistent with Section 2713 of Federal H.R Select over-the-counter medications as determined by the Plan in an equivalent prescription dosage strength will be covered under this Endorsement for the Non-Formulary Member Responsibility. Coverage of the selected over-the-counter medications requires a physician prescription. Only one drug and Rx Unit will be dispensed per prescription. The Rx Unit quantity is determined by FDA labeling, the dosage required, or the Plan Formulary guidelines. Please note: Member Responsibility is required for each Rx Unit, container, or prepackaged item. Oral Contraceptives may be dispensed in a three (3) month supply; however, Copayment, Deductible and/or Coinsurance is required for each month s supply. Value Formulary drugs are offered at no Member Responsibility on a temporary basis to individuals that are on or have recently received certain drug(s) and/or receive a new prescription for certain drug(s), as designated by the Plan to promote effective and efficient use of the Plan drug benefits. These drugs are listed on Our website at Our website shall also identify the Plan Criteria applicable to the Value Formulary Drugs. This Value Formulary list may change from time to time without prior notice. Individuals that appear to meet the Plan criteria for Value Formulary Drugs (as such information is available in Plan s claims records) will be notified if they qualify for a Value Formulary drug, when such drugs are temporarily added. Please note, just because You fill a prescription for a Value Formulary drug does not qualify You to receive such drug at no Member Responsibility. Rather, only individuals that meet Plan criteria will receive the selected drug at no Member Responsibility. If You do not satisfy the Value Formulary drug Plan criteria, the drug shall be subject to its applicable Member Responsibility. 2

3 DEFINITIONS: Any capitalized terms used in this Rider and not otherwise defined herein shall have the meaning set forth in the COC. The following definitions apply to this Rider: ALLOWED AMOUNT(S) is a negotiated amount agreed upon with a Participating Pharmacy as payment in full for Covered Prescriptions. ANCILLARY CHARGE means the charge in addition to the Member Responsibility that You are required to pay for a Prescription Drug which, through Your request or that of the Prescribing Provider, has been dispensed by the brand name, even though a Formulary Generic is available. The Ancillary Charge, if any, shall be the difference between the Plan s contracted price for the Non-Formulary or Formulary brand name drug and the contracted price of the generic drug. The Ancillary Charge will be in addition to the appropriate Member Responsibility. You are responsible at the time of service for payment of the Ancillary Charge directly to the Pharmacy. The Ancillary Charge is not a covered charge and does not apply to any Deductible, Coinsurance, or Out-of-Pocket Maximum. BIOSIMILAR DRUG(S) are biological products that are demonstrated to be highly similar to or interchangeable with an FDA-approved biological product. Interchangeable products may be substituted for the reference product by a pharmacist without the intervention of the Prescribing Provider. COPAYMENT means the amount You will be charged by the Pharmacy to dispense or refill any Prescription. You are responsible at the time of service for payment of the Copayment directly to the Pharmacy. COVERED PRESCRIPTION means a Prescription Drug Product for which the Plan authorizes payment or reimbursement. FORMULARY is a list that identifies those Covered Prescriptions and Specialty Drugs which are preferred by the Plan for dispensing to You when appropriate. This list is subject to periodic review and modification. The Formulary applies only to prescription medications dispensed to outpatients by Participating Pharmacies. The Formulary does not apply to inpatient medications or to medications obtained from and/or administered by a Physician. Please note: Inclusion of a drug within the Formulary does not guarantee that Your Provider will prescribe that drug for a particular medical condition or illness. FORMULARY PRESCRIPTION DRUG means a Prescription and Specialty Drug that appears on the Plan s Formulary. GENERIC EQUIVALENT means a brand product that 1) contains the same active ingredient; 2) is identical in strength, dosage form, and route of administration; 3) has the same indication, dosing, and labeling; 4) has the property of having the same biological effects; 5) meets the requirements for strength, purity, and quality; and 6) is manufactured under the same strict manufacturing regulations of the brand prescription drug. GENERIC PRESCRIPTION DRUG means a Prescription Drug Product as being prescribed by its generic and chemical name heading according to the principal ingredient(s) and approved by the Food and Drug Administration. MAINTENANCE MEDICATION(S) are medications as determined by the Plan and are prescribed for chronic, longterm conditions and are taken on a regular, recurring basis. MEMBER RESPONSIBILITY means the dollar amount detailed under Prescription Drug Benefits which must be paid by You to a Pharmacy providing a Prescription Drug Product covered by this Rider. 3

4 NON-FORMULARY PRESCRIPTION DRUG means a Prescription Drug that is not on the Plan s list of Formulary Prescription Drugs. NON-PARTICIPATING PHARMACY means any pharmacy that is not a Participating Pharmacy as defined herein. A Prescription Order or Refill may be obtained through a Non-Participating Pharmacy, however, You may be required to pay for the cost of the Prescription Drug(s) and file a claim for reimbursement. PARTICIPATING MAIL ORDER PHARMACY means a pharmacy that dispenses Maintenance Medications pursuant to a 90 day supply. Prescription Drugs determined by the Plan to be Maintenance Medications on the Formulary and prescribed by a Prescribing Provider can be filled by mail order. Covered Prescriptions may be dispensed at a Participating Retail Pharmacy who agrees in writing to the same terms and conditions that apply to the contractual agreement offered to any Participating Mail Order Pharmacy. PARTICIPATING PHARMACY means a pharmacy which has entered into a written contract with the Plan to provide You prescription services, or on whose behalf a written contract has been made with the Plan which is in effect at the time services are provided. PRESCRIBING PROVIDER means any person holding the degree of Doctor of Medicine, Doctor of Osteopathy, Doctor of Dental Medicine, or Doctor of Dental Surgery or any other provider who is duly licensed in the United States to prescribe medications in the ordinary course of his or her professional practice. PRESCRIPTION DRUG PRODUCT is a medication, product or device registered with and approved by the Food and Drug Administration (FDA), with a National Drug Code (NDC), and dispensed in compliance with federal or state law pursuant to a prescription order or refill. For the purposes of coverage under this Certificate, this definition may include some Plan approved over-the-counter medications or disposable medical supplies (e.g., insulin and diabetic supplies); psychotherapeutic drugs for the treatment of mental illness, other than when administered in a Hospital or Provider s office; and a compound substance when it meets the Plan s criteria and the product is not available commercially. PRESCRIPTION ORDER OR REFILL means the authorization for a legend Prescription Drug issued by a Prescribing Provider who is duly licensed to make such an authorization in the ordinary course of his or her professional practice. PRIOR AUTHORIZATION is the process defined by the Plan of obtaining approval for certain Prescription Drug Products, prior to dispensing, using guidelines approved by the Plan. The process includes determination of eligibility, determination of Covered Services, determination of Medical Necessity, and implications about the use of Participating and Non-Participating Providers. SPECIALTY PRESCRIPTION DRUGS means medications, including biologics, which are used to treat chronic conditions, may require specialized delivery and administration, or may require patient monitoring on an ongoing basis. Examples of chronic conditions that these drugs treat include, but are not limited to, cancer, HIV/AIDS, hemophilia, hepatitis C, multiple sclerosis, Crohn s disease and ulcerative colitis, rheumatoid and other types of arthritis, and growth hormone deficiency. Those drugs that are considered Specialty Prescription Drugs are available by searching the website at or by contacting Us at the telephone number on Your ID Card. SPECIALTY PHARMACY means a pharmacy that is designated as a Specialty Pharmacy by the Plan for Specialty Prescription Drug Orders or Refills. STEP THERAPY or STEP THERAPY PROGRAM is a clinical program designed to help You receive the most 4

5 appropriate, safe, and cost effective drug for treating Your condition by utilizing evidence-based protocols and guidelines approved by the Plan. TIER 1 FORMULARY means the group of medications on the Plan s Formulary that includes: 1. generic Prescription Drugs that the Plan has designated as Tier 1; 2. the select brand name Prescription Drugs that the Plan has designated as Tier 1; and 3. non-prescription Drugs that the Plan has designated as Tier 1. TIER 2 FORMULARY means the group of medications on the Plan s Formulary that includes: 1. brand name Prescription Drugs the Plan has designated as Tier 2; 2. brand name Prescription Drugs that have a narrow therapeutic index (those for which the dose must be monitored through laboratory tests) that the Plan has designated as Tier 2; 3. brand name Prescription Drugs that have newly introduced generics that the Plan has designated as Tier 2; and 4. drugs designated as DESI drugs by the U.S. Food and Drug Administration (FDA) that the Plan has designated as Tier 2. ( DESI drugs are being reviewed for their effectiveness by the FDA because they were approved solely on the basis of their safety prior to 1962.) TIER 3 NON-FORMULARY means Prescription Drugs that are not otherwise excluded under the Agreement and that are not designated as Tier 1 or Tier 2, including brand name and generic Prescription Drugs that are not on the Plan s Formulary. FRAUDULENT USE OF PRESCRIPTION SERVICES: Fraudulent use of prescription services including, but not limited to, allowing an unauthorized person s use of the ID Card or forgery of a prescription drug order, will result in termination of Coverage under the Plan. In addition, You will be responsible for reimbursement of any services provided as a result of fraudulent behavior. PRIOR AUTHORIZATION: Certain Prescription Drug Products require Prior Authorization from the Plan or are subject to a Step Therapy Program in which first-step or prerequisite drugs must be utilized for therapeutic treatment prior to coverage of second-step drugs. Prior Authorization is to be obtained from the Plan by the Prescribing Provider. The list of Prescription Drug Products and the coverage criteria requiring Prior Authorization are subject to periodic review and modification by the Plan. A current list of Prescription Drug Products requiring Prior Authorization or Step Therapy is available by visiting Our website at or by contacting Us at the telephone number on Your ID Card. MEDICARE PART D CREDITABLE COVERAGE NOTICE: The Plan has determined that the prescription drug coverage described in this Rider is, on average for all plan participants, expected to pay out as much as or more than the standard Medicare prescription drug coverage will pay. Because of this, it is considered to be Creditable Coverage. You can keep this coverage and not pay extra if You later decide to enroll in Medicare coverage. If You drop or lose Your coverage with the Plan and do not subsequently enroll in Medicare prescription drug coverage, You may end up paying more for Your Medicare prescription drug coverage if You go sixty-three (63) days or longer without creditable coverage. For more information about Medicare plans that offer prescription drug coverage, visit or call MEDICARE ( ). For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at or call the SSA at (TTY ). 5

6 LIMITATIONS AND EXCLUSIONS: Limitations: 1. Diabetic supplies prescribed by a Physician are limited to insulin syringes, diagnostic strips and lancets and subject to applicable Copayments, Deductible and/or Coinsurance. There is no Coverage for Non-Formulary diabetic supplies. 2. Coverage for syringes is limited to those required for insulin, allergy injections, and Specialty Prescription Drugs as defined by the Plan. 3. Compound medications will be subject to the Tier 3 Non-Formulary Copayment. 4. Contraceptive diaphragms prescribed by a Prescribing Provider are limited to two (2) per year. 5. To promote appropriate utilization, or following manufacturer s recommendations, certain Plan approved medications may have a quantity limit on the amount of medication dispensed and/or Prior Authorization must be obtained prior to dispensing. In addition, the Plan may put controls in place to prevent early refills of medications (i.e. refill-too-soon and cumulative refill-too-soon requirements). 6. We reserve the right to include only one dosage or form of a drug on Our Formulary when the same drug (i.e., a drug with the same active ingredient) is available in different dosages or forms (i.e., dissolvable tablets, capsules, etc) from the same or different manufacturers. The product in the dosage or form that is listed on the Formulary will be covered at the applicable Member Responsibility. The drug, product or products, in different forms or dosages or from the same or different manufacturers not listed on the Formulary will be subject to Tier Coverage of Prescription Drugs, therapeutic devices or supplies requiring a Prescription Order and prescribed by a Prescribing Provider is limited to Plan approved drugs, devices, supplies, or spacers for metered dose inhalers. 8. Coverage through the Mail Order Pharmacy is not available on drugs that cannot be shipped by mail due to state or federal laws or regulations, or when the Plan considers shipment through the mail to be unsafe. Examples of these types of drugs include, but are not limited to, narcotics, amphetamines, DEA controlled substances or anticoagulants. Exclusions: 1. Prescription Drug Products determined not to be Medically Necessary by the Plan. 2. Any Prescription Drug Product requiring Prior Authorization, when such authorization is not obtained from the Plan. 3. Drugs other than prescription drugs as defined above. 4. Drugs used in connection with a non-covered service or non-covered benefit. 5. The Generic Equivalent of any excluded drug. 6. Drug charges exceeding the costs for the same drug in conventional packaging (e.g. unit dose). 7. Any drug, medicine or medication prescribed in doses exceeding the manufacturer-recommended maximum dose documented in the package insert that is approved by the FDA. This exclusion shall not apply to a drug, 6

7 medicine or medication dose that is referenced in one of the standard reference compendia or in generally accepted peer-reviewed medical literature. 8. Prescription Drugs that are Experimental or Investigational, including those labeled Caution-limited by Federal Law to Investigational Use. FDA approved drugs used for investigational indications or at investigational doses and drugs found by the FDA to be ineffective or given as a part of a study. 9. Products not approved by the FDA, Prescription Drugs with no FDA approved indications, and DESI Drugs. This exclusion shall not apply to a drug, medicine or medication that is recognized for the treatment of cancer in one of the standard reference compendia or in substantially accepted peer-review medical literature. 10. All newly FDA approved prescription drugs will not be covered during a six (6) month evaluation period by the Plan. After the six (6) month evaluation period, a determination will be made whether such prescription drugs are Formulary, non-formulary, or non-covered. 11. Any drug, medicine or medication that is to be taken or administered to the individual, in whole or in part, while he or she is a patient in a licensed Hospital, rest home, extended care Facility, convalescent Hospital, nursing home or similar institution. 12. Medication for which the cost is recoverable under any worker s compensation or occupational disease law or any state or government agency, or medication furnished by any other drug or medical service for which there is no charge. 13. Any charge for the administration of any drug. 14. Medications administered by or obtained from a Physician. 15. Prescription Drug Products for which there is normally no charge in professional practice. 16. Replacement Prescription Drug Products resulting from loss, theft, or damage. 17. Contraceptive implant systems and prescription or non-prescription contraceptive devices (e.g., condoms and spermicidal agents. 18. Drugs, oral or injectable, used for the primary purpose of, or in connection with, treating infertility, fertilization, and/or artificial insemination. 19. Extemporaneous dosage forms of natural estrogen or progesterone; or any natural hormone replacement product, including but not limited to oral capsules, suppositories, creams and troches. 20. Injectable medications and Specialty Prescription Drugs, except those designated by the Plan. 21. Drugs covered under the medical plan. 22. Immunization agents, antigens, allergy and biological sera, blood or blood plasma, parenterals, and radiologicals. 23. Drugs, supplies, and equipment used for intravenous treatment. 7

8 24. Durable medical equipment and associated supplies. 25. Devices or supplies of any type, even though requiring a Prescription Order, such as but not limited to, therapeutic devices, support garments, corrective appliances, non-disposable hypodermic needles, syringes or other devices, regardless of their intended use, unless otherwise specified as a Covered benefit in this Endorsement. 26. Drugs that do not require a prescription by federal or state law, that is, over-the-counter drugs or over-the-counter products, unless specifically designated for Coverage by the Plan and obtained from the Pharmacy with a Prescription Order or Refill. Also excluded are Prescription medications that are not for treatment of illness, injury, or have an over-the-counter equivalent, unless otherwise specified. 27. Any Prescription Drug Product that is an active metabolite, stereoisomer, prodrug (precursor) or altered formulation of another drug and is not clinically superior to that drug as determined by the Plan. 28. Compound prescriptions are excluded unless all of the following apply: a) there is no suitable commerciallyavailable alternative available; b) the main active ingredient is a Covered Prescription Drug; c) the purpose is solely to prepare a dose form that is Medically Necessary and is documented by the Prescribing Provider; and d) the claim is submitted electronically by the Pharmacy. 29. Mental Illness and/or chemical dependency services for the following: 1) services utilizing methadone treatment as maintenance, LAAM (1-Alpha-Acetyl-Methadol), cyclazocine, or their equivalent; except where methadone or its equivalent is used as medically prescribed treatment in a federally approved detoxification program for drug abuse; and 2) services and treatment provided in connection with or to comply with involuntary commitments, police detentions and other similar arrangements. 30. All prescription weight loss medications including, but not limited to, appetite suppressants. 31. Prescription Drug Products prescribed for cosmetic purposes only including, but not limited to, those for hair loss, aging, skin lightening, or nail fungus. 32. Vitamins, herbal, and dietary supplement Prescription Drug Products except as required to be covered by law. Prenatal vitamins that require a prescription are covered. 33. Oral dental preparations and fluoride rinses, except pediatric fluoride tablets or drops as specified by the Plan. CONDITIONS 1. The Plan and its designees shall have the right to release any and all records concerning health care services that are necessary to implement and administer the terms of this Rider or for appropriate medical/pharmaceutical review or quality assessment. 2. The Plan shall not be liable for any claim, injury, demand or judgment based on tort or other grounds (including warranty of drugs) arising out of or in connection with the sale, compounding, dispensing, manufacturing, or use of any Prescription Drug whether or not Covered under this Rider. GENERAL PROVISIONS 1. Your Coverage under this Rider will end when Coverage under the Agreement ends. 8

9 2. Nothing herein shall be held to vary, alter, waive, or extend any of the definitions, terms, conditions, provisions, agreements or limitations of the Agreement, other than as stated above. 3. Discounts and Rebates. You understand and agree that the Plan may receive a retrospective discount or rebate from a Participating Provider or vendor related to the aggregate volume of services, supplies, equipment or pharmaceuticals purchased by persons enrolled in health care plans offered or administered by the Plan and its affiliates. You shall not share in such retrospective volume-based discounts or rebates. However, such rebates will be considered, in the aggregate, in the Plan's prospective premium calculations. 9