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 xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-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 equipment or supplies. The total amount You may pay for a Covered Drug that contains insulin and is used to treat diabetes will not exceed the amount shown on Your SCHEDULE OF COPAYMENT AND BENEFIT LIMITS, up to a 30-day supply, regardless of the amount or type of insulin needed to fill the Prescription Order. The preferred insulin drugs are identified on Your Drug List and does not include an insulin drug administered intravenously. Insulin drugs obtained from a non-Participating Pharmacy or not identified as a Preferred insulin drug may be subject to Copayment or dollar maximums, if applicable. Exceptions will not be made for drugs not identified as a Preferred insulin drug or for an excluded drug.
Appears in 2 contracts
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 xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-xxx.xxxxxx.xxx/xxxxxx/xxxxxxxxxxxx-xxxx-xxxx- 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 SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and pricing differences that may apply to the Covered Drug dispensed. 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 the pharmacist is unable to contact your Health Care Practitioner after reasonable effort; • The the pharmacist has documentation showing the patient was previously prescribed insulin or insulin-related equipment or supplies by a Health Care Practitioner; and • The 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 equipment or supplies. The total amount You may pay for a Covered Drug that contains insulin and is used to treat diabetes will not exceed the amount shown on Your SCHEDULE OF COPAYMENT COPAYMENTS AND BENEFIT LIMITS, up to a 30-day supply, regardless of the amount or type of insulin needed to fill the Prescription Order. The preferred insulin drugs are identified on Your Drug List and does not include an insulin drug administered intravenously. Insulin drugs obtained from a non-Participating Pharmacy or not identified as a Preferred insulin drug may be subject to Copayment or dollar maximums, if applicable. Exceptions will not be made for drugs not identified as a Preferred insulin drug or for an excluded drug.
Appears in 2 contracts
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 xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-xxx.xxxxxx.xxx/xxxxxx/xxxxxxxxxxxx-xxxx-xxxx- 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 the pharmacist is unable to contact your Health Care Practitioner after reasonable effort; • The the pharmacist has documentation showing the patient was previously prescribed insulin or insulin-related equipment or supplies by a Health Care Practitioner; and • The 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 equipment or supplies. The total amount You may pay for a Covered Drug that contains insulin and is used to treat diabetes will not exceed the amount shown on Your SCHEDULE OF COPAYMENT COPAYMENTS AND BENEFIT LIMITS, up to a 30-day supply, regardless of the amount or type of insulin needed to fill the Prescription Order. The preferred insulin drugs are identified on Your Drug List and does not include an insulin drug administered intravenously. Insulin drugs obtained from a non-Participating Pharmacy or not identified as a Preferred insulin drug may be subject to Copayment or dollar maximums, if applicable. Exceptions will not be made for drugs not identified as a Preferred insulin drug or for an excluded drug.
Appears in 2 contracts
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 xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-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 BENEFIT LIMITS and pricing differences that may apply to the Schedule of Copayments and Covered Drug dispensed. 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. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. 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 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 from 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 equipment or supplies. The total amount You may pay for a Covered Drug that contains insulin and is used to treat diabetes will not exceed the amount shown on Your SCHEDULE OF COPAYMENT AND BENEFIT LIMITS, up to a 30-day supply, regardless of the amount or type of insulin needed to fill the Prescription Order. The preferred insulin drugs are identified on Your Drug List and does not include an insulin drug administered intravenously. Insulin drugs obtained from a non-Participating Pharmacy or not identified as a Preferred insulin drug may be subject to Copayment or dollar maximums, if applicable. Exceptions will not be made for drugs not identified as a Preferred insulin drug or for an excluded drugrequired.
Appears in 2 contracts
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 xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-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 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. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. • 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 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 from 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 equipment or supplies. The total amount You may pay for a Covered Drug that contains insulin and is used to treat diabetes will not exceed the amount shown on Your SCHEDULE OF COPAYMENT AND BENEFIT LIMITS, up to a 30-day supply, regardless of the amount or type of insulin needed to fill the Prescription Order. The preferred insulin drugs are identified on Your Drug List and does not include an insulin drug administered intravenously. Insulin drugs obtained from a non-Participating Pharmacy or not identified as a Preferred insulin drug may be subject to Copayment or dollar maximums, if applicable. Exceptions will not be made for drugs not identified as a Preferred insulin drug or for an excluded drugrequired.
Appears in 2 contracts
Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life-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 xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- xxxxx://xxx.xxxxxx.xxx/member/prescription- drug-plan-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 SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and pricing differences that may apply to the Covered Drug dispensed. 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. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. 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 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 from Your 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 equipment or supplies. The total amount You may pay for a Covered Drug that contains insulin and is used to treat diabetes will not exceed the amount shown on Your SCHEDULE OF COPAYMENT AND BENEFIT LIMITS, up to a 30-day supply, regardless of the amount or type of insulin needed to fill the Prescription Order. The preferred insulin drugs are identified on Your Drug List and does not include an insulin drug administered intravenously. Insulin drugs obtained from a non-Participating Pharmacy or not identified as a Preferred insulin drug may be subject to Copayment or dollar maximums, if applicable. Exceptions will not be made for drugs not identified as a Preferred insulin drug or for an excluded drugrequired.
Appears in 1 contract
Samples: Certificate of Coverage
Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life-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 xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- xxxxx://xxx.xxxxxx.xxx/member/prescription- drug-plan-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 Benefit Limits and pricing differences that may apply to the Covered Drug dispensed. 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 equipment or supplies. The total amount You may pay for a Covered Drug that contains insulin and is used to treat diabetes will not exceed the amount shown on Your SCHEDULE OF COPAYMENT AND BENEFIT LIMITS, up to a 30-day supply, regardless of the amount or type of insulin needed to fill the Prescription Order. The preferred insulin drugs are identified on Your Drug List and does not include an insulin drug administered intravenously. Insulin drugs obtained from a non-Participating Pharmacy or not identified as a Preferred insulin drug may be subject to Copayment or dollar maximums, if applicable. Exceptions will not be made for drugs not identified as a Preferred insulin drug or for an excluded drug.
Appears in 1 contract
Samples: Certificate of Coverage