Covered Drugs Clause Samples
The "Covered Drugs" clause defines which pharmaceutical products or medications are included under the terms of an agreement, such as a health plan or supply contract. It typically lists specific drugs by name, category, or formulary, and may outline criteria for inclusion or exclusion, such as FDA approval status or therapeutic class. This clause ensures clarity for all parties regarding which drugs are eligible for coverage or reimbursement, thereby preventing disputes and managing expectations about benefits or obligations.
Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life-threatening illness covered by HMO are available if the drug is on the applicable Drug List and has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: • a prescription drug reference compendium approved by the Texas Department of Insurance; or • substantially accepted peer-reviewed medical literature. For a list of Covered Drugs, You can access the website at ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇-▇▇▇▇-▇▇▇▇- information/drug-lists or You can also contact customer service at the toll-free number on Your identification card. You are responsible for any Copayments for Covered Drugs shown in the Schedule of Copayments and Injectable Drugs. Injectable drugs approved by the FDA for self-administration are covered. Benefits will not be provided under PHARMACY BENEFITS for any self-administered drugs dispensed by a Physician. A separate Copayment will apply to each fill of a prescription purchased on the same day for insulin and insulin syringes. All supplies, including medications and equipment for the control of diabetes will be dispensed as written, unless substitution is approved by Your prescribing Physician or other Health Care Practitioner who issues the written order for the supplies or equipment. A pharmacist may exercise their professional judgement in refilling a Prescription Order for Insulin or Insulin- Related Equipment or Supplies without the authorization of the prescribing Health Care Practitioner in the following situations: • the pharmacist is unable to contact your Health Care Practitioner after reasonable effort; • the pharmacist has documentation showing the patient was previously prescribed insulin or insulin-related equipment or supplies by a Health Care Practitioner; and • the pharmacist accesses the patient to determine whether the emergency refill is appropriate. The quantity of an emergency refill will be the smallest available package and will not exceed a 30-day supply. In addition to the applicable terms provided in the DEFINITIONS section of the Certificate, the following terms will apply specifically to this provision. You are responsible for the same Copayment and any pricing differences that may apply to the items dispensed in the same manner as for nonemergency refills of diabetes equ...
Covered Drugs. Covered outpatient drugs would be defined to include: 1) a drug which could only be dispensed subject to a prescription and which was described in subparagraph (A)(i) or (A)(ii) of Section 1927(k)(2) of the Social Security Act (relating to drugs covered under Medicaid); 2) a biological product described in paragraph B of such subsection; 3) insulin described in subparagraph C of such section and medical supplies associated with the injection of insulin; and 4) vaccines licensed under section 351 of the Public Health Service Act. Drugs excluded from Medicaid coverage would be excluded from the definition except for smoking cessation drugs. The definition would include any use of a covered outpatient drug for a medically accepted indication. Drugs, which could be paid for under Medicare Part B, would not be covered under Part D. A plan could elect to exclude a drug, which would otherwise be covered, if the drug was excluded under the formulary and the exclusion was not successfully appealed under the new Section 1860D-3. In addition, a PDP or MA Rx or EFFS Rx plan could exclude from coverage, subject to reconsideration and appeals provisions, any drug, which would not meet Medicare’s definition of medically necessary or was not prescribed in accordance with the plan or Part D.
Covered Drugs. Covered outpatient drugs are defined to include: 1) a drug which could only be dispensed subject to a prescription and which was described in subparagraph A of Section 1927(k)(2) of the Social Security Act (relating to drugs covered under Medicaid); 2) a biological product described in paragraph B of such subsection; 3) insulin described in subparagraph C of such section and medical supplies associated with the injection of insulin (as defined in regulations of the Secretary); and 4) vaccines licensed under section 351 of the Public Health Service Act. It is the intent of conferees that the definition of insulin, and medical supplies associated with the administration of insulin, as a covered prescription drug shall include medical supplies that the Secretary determines to be reasonable and necessary, such as insulin, insulin syringes, and insulin delivery devices that are not otherwise covered under the durable medical equipment benefit. Drugs excluded from Medicaid coverage are excluded from the definition except for smoking cessation drugs. The definition would include any use of a covered outpatient drug for a medically accepted indication. Drugs, which can be paid for under Medicare Part B, are not covered under Part D. A PDP plan or MA-PD plan could exclude from coverage, subject to reconsideration and appeals provisions, any drug which would not meet Medicare’s definition of medically necessary or was not prescribed in accordance with the plan or Part D. Present Law House Bill Senate Bill Conference Agreement
Covered Drugs. The New Section 1860 D would define covered drugs as drugs, biological products, and insulin (including syringes, and necessary medical supplies associated with the administration of insulin, as defined by the Administrator) which are covered under Medicaid and vaccines licensed under Section 351 of the Public Health Service Act. Coverage would be extended to any use of a covered drug for a medically accepted indication. The term would not include drugs or classes of drugs, or their medical uses, which could be excluded from coverage under Medicaid, except for smoking cessation agents. The term would not include drugs currently covered under Medicare Part A or Medicare Part B to the extent payment is available under those Parts. A drug prescribed for an individual, which would ordinarily be a covered drug, would not be covered if a plan’s formulary excluded the drug and the exclusion was not successfully resolved. Further, a Medicare Prescription Drug plan or a MedicareAdvantage plan could exclude drugs which did not meet Medicare’s definition of “reasonable and necessary” under Section 1862(a) of the Act or which were not prescribed in accordance with the requirements of the plan or Part D.
Covered Drugs. Benefits for Medically Necessary covered drugs prescribed to treat You for a chronic, disabling, or life- threatening illness covered by HMO are available if the drug has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: • a prescription drug reference compendium approved by the Texas Department of Insurance, or • substantially accepted peer- reviewed medical literature. As new drugs are approved by the Food and Drug Administration (FDA), such drugs, unless the intended use is specifically excluded by HMO, are eligible for benefits. Some equivalent drugs are manufactured under multiple brand names. In such cases, HMO may limit benefits to only one of the brand equivalents available. Copayments for covered drugs are shown in the Schedule of Copayments and Benefit Limits. Injectable Drugs. Injectable drugs approved by the FDA for self- administration are covered. You are responsible for any Copayments as shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and pricing differences that may apply to the covered drug dispensed. Injectable drugs include, but are not limited to, insulin and Imitrex. The day supply of disposable syringes and needles You will need for self- administration injections will be limited on each occasion dispensed to amounts appropriate to the dosage amounts of covered injectable drugsactuallyprescribed anddispensed, butcannot exceed 100 syringesand needlesper Prescription Order in a 30- day period. • Immunoglobulin E and non- immunoglobulin E mediated allergies to multiple food proteins; • Severe food protein- induced enterocolitis syndromes; • Eosinophilic disorders, as evidenced by the results of biopsy; and • Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from Your Health Care Practitioner is required.
Covered Drugs. 1. Anaphylaxis Agents (Epipen, ▇▇▇-Kit, epinephrine, etc.) – Limited to 2 per Rx.
2. Specialty/Biotech Medications administered in a physician’s office require prior authorization and are available through a limited network of providers. The current list of these medications is available at ▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇. Please contact MaxCare customer service for assistance in locating a participating specialty/biotech pharmacy provider.
3. Chemotherapy drugs administered in a physician’s office require prior authorization and are available through a limited network of providers. The current list of these medications is available at ▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇. Please contact MaxCare customer service for assistance in locating a participating pharmacy provider for chemotherapy drugs.
Covered Drugs. The provisions of the following paragraphs 1 – 3 apply to Attachment A and this Agreement.
Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life‐threatening illness covered by HMO are available if the drug has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: • a prescription drug reference compendium approved by the Texas Department of Insurance, or • substantially accepted peer‐reviewed medical literature. As new drugs are approved by the Food and Drug Administration (FDA), such drugs, unless the intended use is specifically excluded by HMO, may be eligible for benefits. Copayments for Covered Drugs are shown in the Schedule of Copayments and Benefit Limits. Injectable Drugs. Injectable drugs approved by the FDA for self‐administration are covered. Benefits will not be provided under PHARMACY BENEFITS for any self‐administered drugs dispensed by a Physician. All supplies, including medications and equipment for the control of diabetes, will be dispensed as written unless substitution is approved by Your prescribing Physician or other Health Care Practitioner who issues the written order for the supplies or equipment. • Immunoglobulin E and non‐immunoglobulin E mediated allergies to multiple food proteins; • Severe food protein‐induced enterocolitis syndromes; • Eosinophilic disorders, as evidenced by the results of biopsy; and • Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from Your Health Care Practitioner is required. When You need a Prescription Order filled, You should use a Participating Pharmacy. Each prescription or refill is subject to the Copayment shown in the Schedule of Copayments and Benefit Limits.
Covered Drugs. Benefits for Medically Necessary covered drugs prescribed to treat You for a chronic, disabling, or life- threatening illness covered by HMO are available if the drug is on the applicable Drug List and has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: • a prescription drug reference compendium approved by the Texas Department of Insurance, or • substantially accepted peer-reviewed medical literature. As new drugs are approved by the Food and Drug Administration (FDA), such drugs, unless the intended use is specifically excluded by HMO, may be eligible for benefits if included on the applicable Drug List. Some equivalent drugs are manufactured under multiple brand names. In such cases, HMO may limit benefits to only one of the brand equivalents available. You are responsible for any Copayments for covered drugs shown in the Schedule of Copayments and Benefit Limits and pricing differences that may apply to the covered drug dispensed. The day supply of disposable syringes and needles You will need for self-administered injections will be limited on each occasion dispensed to amounts appropriate to the dosage amounts of covered injectable drugs actually prescribed and dispensed, but cannot exceed 100 syringes and needles per Prescription Order in a 30-day period. A separate Copayment will apply to each fill of a prescription purchased on the same day for insulin and insulin syringes.