Outpatient Prescription Drugs. Data Collection and Editing in the 1996 Medical Expenditure Panel Survey (HC-010A) (MEPS Methodology Report No. 12, AHRQ Pub. No. 01-0002). Rockville, MD: Agency for Healthcare Research and Quality. Xxxxxxx, X.X., Xxxxxx, X., and Xxxxxx, III, X.X. (Eds.). (1999) Informing American Health Care Policy. San Francisco, CA: Jossey-Bass Inc. Xxxx, B.V., Xxxxxxxx, X.X., Xxxxxx, X.X., Xxxxx, X.X., Xxxxxx, R.E., Xxxxxxx, L., Xxxxxxxx, S.C., and Xxxxxxxx, R. (1996). Technical Manual: Statistical Methods and Algorithms Used in SUDAAN Release 7.0. Research Triangle Park, NC: Research Triangle Institute. Xxxxx, X.X., Xxxx, S.C., and Xxxxxx, E. Comparison of Retail Drug Prices in the MEPS and MarketScan: Implications for MEPS Editing Rules. Agency for Healthcare Research and Quality Working Paper No. 10001, February 2010.
Outpatient Prescription Drugs. 1. Benefits are provided for Covered Medications appearing on the Formulary when prescribed by a Professional Provider in connection with a Covered Service, when purchased at a Participating Pharmacy Provider upon presentation of a valid Identification Card and when dispensed on or after the Member’s Effective Date for Outpatient use. Benefits for Covered Medications are provided in the amounts specified in SECTION SB - SCHEDULE OF BENEFITS of this Agreement. Coverage is provided for:
Outpatient Prescription Drugs. Data Collection and Editing in the 2011 Medical Expenditure Panel Survey. (Methodology Report No. 29). Rockville, MD: Agency for Healthcare Research and Quality. Xxxx, S.C., Xxxxxxx, X.X., and Xxxxx, X.X. (2011). Implications of the Accuracy of MEPS Prescription Drug Data for Health Services Research. Inquiry 48(3).
Outpatient Prescription Drugs. Coverage is only provided for prescription drugs prescribed by a licensed Physician. Imported drugs are covered only if the Ministry of Health approves the drug; No Coverage is provided for those pharmaceuticals specifically excluded in Section 11.
Outpatient Prescription Drugs. Introduction/Prior We provide Benefits for drugs and medicines obtained at a participating Authorization: pharmacy that require a Physician’s prescription. Certain medications or classes of medications may require Prior Authorization. To receive Prior Authorization, Your Physician will need to submit to Us a statement of Medical Necessity. Certain medications are subject to utilization programs that require You to try to use a therapeutic alternative before another medication will be considered a Covered Service. Your Physician may submit to Us a statement of Medical Necessity if the utilization program is not appropriate for Your medical condition. For participating providers, You must always pay the lower of either: (a) Your applicable Prescription Drug Copayment, specified in the Benefit Schedule; or (b) the participating pharmacy’s Usual and Customary Charge if the Usual and Customary Charge is less than Your Copayment. For purposes of this paragraph, Usual and Customary Charge means the amount that the participating pharmacy would have charged You if You were a cash paying customer. Such amount includes all applicable discounts, including, without limitation, senior citizen’s discounts, coupon discounts, non-insurance discounts, or other special discounts offered to attract customers. Drug Rebates and We contract with a pharmacy benefit manager (“PBM”) for certain Credits: prescription drug rebate administration services. Under the agreement, PBM obtains rebates from drug manufacturers based on the utilization of certain branded prescription products by Covered Persons. As partial consideration for these services, pharmaceutical manufacturers pay administrative fees to PBM and PBM retains the benefit of the funds prior to disbursement. Administrative fees retained by PBM in connection with its rebate program do not exceed the greater of (i) 4.58% of the Average Wholesale Price, or (ii) 5.5% of the wholesale acquisition cost of the products. PBM may also receive other service fees from manufacturers as compensation for various services unrelated to rebates or rebate-associated administrative fees. We receive rebates from the PBM and may from time to time receive financial credits, and/or other amounts (collectively “Financial Credits”) from network pharmacies, drug manufacturers, or the PBM. We retain sole and exclusive right to all Financial Credits and may use such Financial Credits in Our sole and absolute discretion (including, for example, to help...
Outpatient Prescription Drugs ο Most Specialty Drugs, including self-injectable drugs and hemophilia factors, must have Prior Authorization through the Prescription Drugs benefit and may need to be dispensed through the specialty pharmacy vendor. Please refer to the Essential Drug List to identify which drugs require Prior Authorization. Urgent or emergent drugs that are Medically Necessary to begin immediately may be obtained at a retail pharmacy. ο Other Prescription Drugs, as indicated in the Essential Drug List, may require Prior Authorization. Refer to the Essential Drug List to identify which drugs require Prior Authorization.
Outpatient Prescription Drugs. Benefits defined under the Health Resources and Services Administration (HRSA) requirement include one breast pump per Pregnancy in conjunction with childbirth. Breast pumps must be ordered by or provided by a Physician. You can find more information on how to access Benefits for breast pumps by contacting us at xxx.xxxxx.xxx/xxxxxxxx or the telephone number on your ID card. If more than one breast pump can meet your needs, Benefits are available only for the most cost-effective pump. We will determine the following: • Which pump is the most cost-effective. SAMPLE • Whether the pump should be purchased or rented (and the duration of any rental). • Timing of purchase or rental.
Outpatient Prescription Drugs. Benefits for Medically Necessary Covered Drugs (subject to the Generics Plus Drug List and other limita- tions and exclusions described below) prescribed to treat you for a chronic, disabling, or life- threatening illness are available under the plan if the drug: S Has been approved by the United States Food and Drug Administration (FDA) for at least one indication; and; S Is recognized by the following for treatmentof the indication for which the drug is prescribed a prescription drug reference compendium approved by the Department of Insurance, or substantially accepted peer- reviewed medical literature. As new drugs are approved by the United States Food and Drug Administration (FDA), such drugs, unless the intended use is specifically excluded under the plan, are eligible for benefits. Some equivalent drugs are manufactured under multiple brand names. In such cases, Blue Cross and Blue Shield may limit benefits to only one of the brand equivalents available. Benefits are available for Covered Drugs as indicated on your Schedule Page. YOUR IDENTIFICATION CARD The Identification Card you received is the key to your use of Outpatient Prescription Drugs. It tells Partici- pating Pharmacies that you are entitled to prescription drug benefits under Outpatient Prescription Drugs. Participating Pharmacies are not permitted to file Claims with Blue Cross and Blue Shield unless you pres- ent the Identification Card with your Prescription Order.
Outpatient Prescription Drugs. F.11.01.
Outpatient Prescription Drugs. If you require certain Pharmaceutical Products, including specialty Pharmaceutical Products, we may direct you to a Designated Dispensing Entity. Such Dispensing Entities may include an outpatient pharmacy, specialty pharmacy, Home Health Agency provider, Hospital-affiliated pharmacy or hemophilia treatment center contracted pharmacy. If you/your provider are directed to a Designated Dispensing Entity and you/your provider choose not to get your Pharmaceutical Product from a Designated Dispensing Entity, Benefits are not available for that Pharmaceutical Product, unless the provider or its intermediary agrees in writing to accept reimbursement, including copayment, at the same rate as a Designated Dispensing Entity. Certain Pharmaceutical Products are subject to step therapy requirements. This means that in order to receive Benefits for such Pharmaceutical Products, you must use a different Pharmaceutical Product and/or prescription drug product first. You may find out whether a particular Pharmaceutical Product is subject to step therapy requirements by contacting us at xxx.xxxxx.xxx/xxxxxxxx or the telephone number on your ID card. We may have certain programs in which you may receive an enhanced Benefit based on your actions such as adherence/compliance to medication or treatment regimens and/or participation in health management programs. You may access information on these programs by contacting us at xxx.xxxxx.xxx/xxxxxxxx or the telephone number on your ID card.