Prescription Drugs. The agreement may impose a variety of limits affecting the scope or duration of benefits that are not expressed numerically. An example of these types of treatments limit is preauthorization. Preauthorization is applied to behavioral health services in the same way as medical benefits. The only exception is except where clinically appropriate standards of care may permit a difference. Mental disorders are covered under Section A. Mental Health Services. Substance use disorders are covered under Section
Prescription Drugs. $10 copayment per prescription or refill for up to a 30 day supply of Generic Plus drugs. A copay is incurred for each type of insulin. • $30 copayment per prescription or refill for up to a 30 day supply of all other formulary brand drugs. A copay is incurred for each type of insulin. • $75 copayment per prescription or refill for up to a 30 day supply of non-formulary drugs. • If a chemically equivalent generic drug is available and the employee takes the brand drug, the employee pays the generic copay and the difference in cost between the brand drug and generic drug. • Annual out of pocket (OOP) maximum for prescription drug copayments of $750 per person or $1500 per family. Copayments for the cost difference between generic and brand name drugs do not count against this annual OOP maximum.
Prescription Drugs. The prescription drug plan shall include the following:
Prescription Drugs. The prescription drug benefit for the Total Choice, Health Guard PPO and Select Care POS Plans shall implement the following. There shall be an initial deductible of twenty- five dollars ($25.00) per patient for each year. As is currently the case, the State may select the Pharmacy Benefits Manager, who shall implement the terms of this section in accordance with its contract with the State. The Pharmacy Benefits Manager shall, in accordance with industry standards, categorize (and may subsequently recategorize) prescription drugs into three (3) tiers: generic, preferred brand and non-preferred brand. There shall be a co-payment by the patient on each prescription of ten percent (10%) for generic drugs, twenty percent (20%) for preferred brands, and forty percent (40%) for non-preferred brands. If there is no effective generic or preferred alternative to it, the co-payment for non-preferred brands shall be twenty percent (20%). There shall be a maximum out-of-pocket by the patient, in addition to the deductible, of six hundred seventy-five dollars ($675.00), effective January 1, 2009, and seven hundred fifty dollars ($750) effective January 1, 2010. Co-payments made at the forty percent (40%) rate for non-preferred brands shall not be counted toward the maximum out-of-pocket limit (i.e., there shall be no maximum out-of-pocket limit for co-payments made at the forty percent (40%) rate for non- preferred brands). The maximum out-of-pocket shall apply to all co-payments made at the ten percent (10%) or twenty percent (20%) rate. The maximum out-of-pocket limit shall also apply to all co-payments made for Specialty drugs at the forty percent (40%) rate. The Pharmacy Benefits manager shall prior to implementing the list, and annually thereafter, provide a proposed list of the division of drugs into tiers prior to the implementation of such drug list. The parties will meet, review and discuss the list promptly. The parties must consider each other’s positions in good faith. During any year, the Pharmacy Benefits Manager may bring forward revisions for discussion and review in accordance with this paragraph. If VSEA contends that the list or revision finally implemented by the State violates this agreement, the VSEA retains all rights to contest this action.
Prescription Drugs. This plan covers prescription drugs and diabetic equipment or supplies. When they are purchased from a pharmacy, prescription drugs and diabetic equipment or supplies are covered as a pharmacy benefit. When the prescription drug requires administration by a provider other than a pharmacist (or the FDA approved recommendation is administration by a provider other than a pharmacist), the prescription drug is covered as a medical benefit referred to as “medical prescription drugs”. Please see Pharmacy Benefits subsection A and Medical Benefits subsection B below for information about how these prescription drugs are covered. Prescription drugs and diabetic equipment or supplies are covered when dispensed using the following guidelines: • the prescription must be medically necessary, consistent with the physician’s diagnosis, ordered by a physician whose license allows him or her to order it, filled at a pharmacy whose license allows such a prescription to be filled, and filled according to state and federal laws; • the prescription must consist of legend drugs that require a physician’s prescription under law, or compound medications made up of at least one legend drug requiring a physician’s prescription under law; • the prescription must be dispensed at the proper place of service as determined by our Pharmacy and Therapeutics Committee. For example, certain prescription drugs may only be covered when obtained from a specialty pharmacy; and • the prescription is limited to the quantities authorized by your physician not to exceed the quantity listed in the Summary of Pharmacy Benefits.
Prescription Drugs. Drugs prescribed while in-patient are covered at a hundred percent (100%).
Prescription Drugs. Prescription drugs are only covered if first prescribed during a hospitalization or after outpatient surgery and for a maximum period of six (6) months, unless the Insurer approves an extension. In all cases, a copy of the prescription from the attending physician must accompany the claim.
Prescription Drugs. In addition, to the benefit limits and level of coverage shown in the Summary of Benefits, we cover office visits to a podiatrist and to an optometrist or ophthalmologist for members with diabetes. We cover other office visits. For office visits to a podiatrist, see Section 3.24 - Office Visits. For vision care, see Section 3.39 - Vision Care Services.
Prescription Drugs. Medications whose sale and use are legally restricted to the order of a physician.
Prescription Drugs. In order to promote the usage of generic prescription drugs to reduce costs while maintaining the quality of care, the Pharmacy Benefit Manager (PBM) will automatically substitute an approved generic drug for prescriptions written for multi-source brand name drugs, except for a list of narrow therapeutic index agents, e.g.
