Outpatient Prescription Drug Benefits. Prescription Drugs obtained from a Participating Pharmacy. You may call the 800 number on your identification card for assistance in a Participating Pharmacy. The Formulary is subject to change. Drugs may be deleted from the Formulary during the year if significant safety issues arise, or if new products come to the market that are superior in efficiency and or safety. If a New Drug is determined as safe and effective as currently available therapies, the cost effectiveness of the drug is reviewed. Typically, if the cost is comparable or better than existing therapies, the drug is added to the Formulary. Drugs listed on the Formulary will be included in Covered Drugs if they not excluded, the appropriate Copay and/or Deductible and Coinsurance is paid, and any required Prior Authorization is received. Some Prescription Drugs are subject to Step Therapy. Step Therapy is an automated process that defines how and when a particular drug can be dispensed based on your drug history. Step therapy usually requires the use of one or more prerequisite drugs prior to the use of another drug. You may obtain a copy of the current Formulary at no charge by contacting us at: Address: US Health and Life Insurance Company Attention: Customer Service [000 Xxxxx Xxxxx, Xxxxx 000 Troy, MI 48098] Telephone: [000-000-0000] Website: [xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx] Covered Prescription Drugs The Company covers only drugs that are:
Outpatient Prescription Drug Benefits. This benefit includes access to Blue Shield’s Participating Pharmacy Network. By presenting your Blue Shield Identifi- cation Card to a Participating Pharmacy you will pay Blue Shield’s contracted rate for covered medication. This will significantly reduce your out of pocket costs for covered medications. Please see the section entitled “Obtaining Out- patient Prescription Drugs at a Participating Pharmacy” for more details. The following prescription drug benefit is separate from the Shield Spectrum PPO 5500 coverage. The Calendar Year Maximum Copayment and Medical Plan Deductible provisions do not apply to the outpatient prescrip- tion drug benefit; however, the general provisions and exclu- sions of the Shield Spectrum PPO 5500 contract shall apply. Benefits for covered Brand Name Drugs are subject to a per Member, per Calendar Year Brand Name Drug Deductible as shown in the Summary of Benefits. Note: Except for covered emergencies, no benefits are pro- vided for drugs received from Non-Participating Pharmacies.
Outpatient Prescription Drug Benefits. Prescription Drugs obtained from a Participating Pharmacy. You may call the 800 number on your identification card for assistance in a Participating Pharmacy. The Formulary is subject to change. Drugs may be deleted from the Formulary during the year if significant safety issues arise, or if new products come to the market that are superior in efficiency and or safety. If a new drug is determined as safe and effective as currently available therapies, the cost effectiveness of the drug is reviewed. Typically, if the cost is comparable or better than existing therapies, the drug is added to the Formulary. Drugs listed on the Formulary will be included in Covered Drugs if they not excluded, the appropriate Copay and/or Deductible and Coinsurance is paid, and any required Prior Authorization is received. Some Prescription Drugs are subject to Step Therapy. Step Therapy is an automated process that defines how and when a particular drug can be dispensed based on your drug history. Step therapy usually requires the use of one or more prerequisite drugs prior to the use of another drug. You may request access to clinically appropriate drugs not covered or obtain a copy of the current Formulary at no charge by contacting us at: Address: US Health and Life Insurance Company Attention: Customer Service [000 Xxxxx Xxxxx, Xxxxx 000 Troy, MI 48098] Telephone: [000-000-0000] Website: [xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx] Covered Prescription Drugs The Company covers only drugs that are:
Outpatient Prescription Drug Benefits. The following prescription drug Benefit is separate from the Health Plan coverage. The Calendar Year maximum Co- payments and the Coordination of Benefits provision do not apply to this Outpatient Prescription Drug Benefits Supple- ment; however, the general provisions and exclusions of the Health Plan contract shall apply. Benefits are provided for Outpatient prescription Drugs which meet all of the requirements specified in this supple- ment, are prescribed by the Member’s Personal Physician, are obtained from a Participating Pharmacy, and are listed in the Drug Formulary. Drug coverage is based on the use of Blue Shield’s Outpatient Drug Formulary, which is updated on an ongoing basis by Blue Shield’s Pharmacy and Therapeutics Committee. A Non-Formulary Drug may be covered but only through the prior authorization process described herein. Select Drugs and Drug dosages and most Specialty Drugs require prior authorization by Blue Shield for Medical Neces- sity, appropriateness of therapy or when effective, lower cost alternatives are available. Your Physician may request prior authorization from Blue Shield. Coverage for selected Drugs may be limited to a specific quantity as described in “Limitation on Quantity of Drugs that may be Obtained per Prescription or Refill”. Outpatient Drug Formulary Medications are selected for inclusion in Blue Shield’s Out- patient Drug Formulary based on safety, efficacy, FDA bioequivalency data and then cost. New drugs and clinical data are reviewed regularly to update the Formulary. Drugs considered for inclusion or exclusion from the Formulary are reviewed by Blue Shield’s Pharmacy and Therapeutics Committee during scheduled meetings four times a year. A Non-Formulary Drug may be covered only if prior author- ized by Blue Shield. Your Physician may request prior au- thorization. For instructions regarding obtaining prior author- ization, see the section entitled Prior Authorization Process for Non-Formulary Drugs later in this supplement. Members may call Blue Shield Member Services at the num- ber listed on their Blue Shield Identification Card to inquire if a specific drug is included in the Formulary. Member Ser- vices can also provide Members with a printed copy of the Formulary. Members may also access the Formulary through the Blue Shield of California web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Definitions Brand Name Drugs — Drugs which are FDA approved ei- ther (1) after a new drug application, or (2) after an abbr...
Outpatient Prescription Drug Benefits. Prescription Drugs obtained from a Participating Pharmacy. You may call the 800 number on your identification card for assistance in a Participating Pharmacy. The Formulary is subject to change. Modifications will occur at the time of the plan renewal and coverage for the drug being removed will continue to be covered until the renewal date of the plan. Drugs may be deleted from the Formulary during the year if significant safety issues arise, or if new products come to the market that are superior in efficiency and or safety. If a new drug is determined as safe and effective as currently available therapies, the cost effectiveness of the drug is reviewed. Typically, if the cost is comparable or better than existing therapies, the drug is added to the Formulary. Drugs listed on the Formulary will be included in Covered Drugs if they are not excluded, the appropriate Copay and/or Deductible and Coinsurance is paid, and any required Prior Authorization is received. Some Prescription Drugs are subject to Step Therapy. Step Therapy is an automated process that defines how and when a particular drug can be dispensed based on your drug history. Step therapy usually requires the use of one or more prerequisite drugs prior to the use of another drug. The Step Therapy process does not apply to coverage for stage-four advanced, metastatic cancer and associated conditions. No proof of history of failure or failure to respond to a different drug will be required. This applies when the drug prescribed is consistent with best practices for the treatment of stage-four advanced, metastatic cancer or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by the USFDA. You may obtain a copy of the current Formulary at no charge by contacting us at: Address: US Health and Life Insurance Company Attention: Customer Service [000 Xxxxx Xxxxx, Xxxxx 000 Troy, MI 48098] Telephone: [000-000-0000] Website: [xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx] Covered Prescription Drugs The Company covers only drugs that are:
