Covered Medications Clause Samples
The "Covered Medications" clause defines which prescription drugs or pharmaceutical products are included under a health insurance plan or pharmacy benefit. It typically lists or references a formulary, specifying which medications are eligible for reimbursement or coverage, and may outline any restrictions, such as prior authorization or step therapy requirements. This clause ensures clarity for both the insurer and the insured regarding which medications are financially supported, helping to manage costs and set expectations for coverage.
Covered Medications i) Prescription drugs listed in the closed formulary;
ii) Over-the-counter drugs listed in the closed formulary, upon presentation of a written prescription order;
iii) Maintenance prescription drugs obtained though a mail service program for up to 90- day supply; and
iv) Selected prescription drugs within, but not limited to, the following drug classifications only when such drugs are covered medications and are dispensed through an exclusive pharmacy provider:
a) Oncology related therapies b) Interferons
c) Agents for multiple sclerosis and neurological related therapies
d) Antiarthritic therapies e) Anticoagulants
f) Hematinic agents
g) Immunomodulators
h) Growth hormones These selected prescription drugs may be ordered by a physician or other health care provider on behalf of the member or the member may submit the prescription order directly to the exclusive pharmacy provider. In either situation, the exclusive pharmacy provider will deliver the prescription drug to the member. Once the prescription drug deductible has been satisfied, benefits will be provided for prescription drugs in the amounts specified in Section C.11.c of this Outline.
Covered Medications. Eligible medications and the refills prescribed by a Participating Provider and dispensed through a Participating pharmacy.