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:
a. Prescription Drugs including Specialty Prescription Drugs obtained from a retail Participating Pharmacy Provider or through a mail service program from a Designated Mail-Order Pharmacy Provider; and
b. Selected Prescription Drugs within, but not limited to, the following drug classifications only when such drugs are Covered Medications and when dispensed through an Exclusive Pharmacy Provider:
i) Oncology related therapies; ii) Interferons;
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. 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:
a. Prescription Drugs, including Specialty Prescription Drugs, obtained from a retail Participating Pharmacy Provider or through a mail service program from a Designated Mail-Order Pharmacy Provider; and
b. Selected Prescription Drugs within, but not limited to, the following drug classifications only when such drugs are Covered Medications and when dispensed through an Exclusive Pharmacy Provider:
i) Oncology related therapies; ii) Interferons;
iii) Agents for multiple sclerosis and neurological related therapies;
iv) Antiarthritic therapies;
v) Anticoagulants;
vi) Hematinic agents;
vii) Immunomodulators; and
viii) 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
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. 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. A step therapy requirement may not be imposed if: • The step therapy drug has not been approved by the U.S. Food and Drug Administration (FDA) for the medical condition being treated; or • The prescribing provider provides supporting medical information to us that a Prescription Drug Product: ▪ Was ordered by a prescribing provider for the Covered Person within the past 180 days; and ▪ Based on the professional judgment of the prescribing provider, was effective in treating the Covered Person’s medical condition. • The prescription drug has been approved by the FDA and: ▪ Is being used to treat the Covered Person’s stage four advanced metastatic cancer; and ▪ Use of the prescription drug is consistent with the FDA-approved indication or the National Comprehensive Cancer Network Drugs & Biologics Compendium indication for the treatment of stage four advanced metastatic cancer; and ▪ Is supported by peer-reviewed medical literature. We will have certain programs in which you 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 can access information on these programs by contacting us at xxx.xxxxx.xxx/xxxxxxxx or the telephone number on your ID card.
Outpatient Prescription Drugs. ▪ Contraceptive services, patient education, and counseling on contraception. ▪ Follow-up services related to contraceptive drugs, devices, products, and procedures. • Screening by Low-dose Mammography which includes, but is not limited to: ▪ A baseline mammogram for women who are 35-39 years of age. ▪ An annual mammogram for women age 40 and over. ▪ A mammogram at the age and intervals considered to be Medically Necessary by the woman's Physician for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors. SAMPLE ▪ A comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when Medically Necessary as determined by a Physician licensed to practice medicine in all of its branches. ▪ A screening MRI when Medically Necessary, as determined by a Physician licensed to practice medicine in all of its branches. • Diagnostic mammography, which includes a screening that is designed to evaluate an abnormality in a breast, including an abnormality seen or suspected on a screening mammogram or a subjective or objective abnormality otherwise detected in the breast, such as a fibrocystic breast condition. • One annual office visit for a whole body skin examination for lesions suspicious for skin cancer. • Medically Necessary pancreatic cancer screening. • Genetic testing of the BRCA1 and BRCA2 genes to detect an increased risk for breast and ovarian cancer if recommended by a health care provider in accordance with the United States Preventive Services Task Force’s recommendations for testing. • A1C testing for prediabetes, type 1 diabetes, and type 2 diabetes in accordance with prediabetes and diabetes risk factors identified by the United States Centers for Disease Control and Prevention. • Follow-up services related to coverage for abortifacients, hormonal therapy to treat gender dysphoria, and human immunodeficiency virus (HIV) pre-exposure prophylaxis and post-exposure prophylaxis. For HSA qualified plans, if payment would disqualify the plan under the Internal Revenue Code, coverage is subject to any applicable deductible. Benefits for screenings that do not meet the criteria above are described under the applicable Covered Health Care Services category in this Policy.
Outpatient Prescription Drugs. See the Hospice Program Benefits section for in- formation about admission into a Hospice program and specialized Skilled Nursing services for Hos- pice care. For information concerning diabetic self-manage- ment training, see the Diabetes Care Benefits sec- tion. Benefits are provided for home infusion and in- jectable medication therapy. Services include home infusion agency Skilled Nursing visits, infu- sion therapy provided in infusion suites associated with a Participating home infusion agency, par- enteral nutrition services, enteral nutritional ser- vices and associated supplements, medical sup- plies used during a covered visit, medications in- jected or administered intravenously, related labo- ratory services, when prescribed by a Doctor of Medicine and provided by a Participating home in- fusion agency. Services related to hemophilia are described separately. This Benefit does not include medications, insulin, insulin syringes, certain Specialty Drugs covered under the Outpatient Prescription Drug Benefit, and services related to hemophilia which are de- scribed below. Services rendered by Non-Participating home in- fusion agencies are not covered unless prior autho- rized by Blue Shield, and there is an executed let- ter of agreement between the Non-Participating home infusion agency and Blue Shield. Shift care and private duty nursing must be prior authorized by Blue Shield. Benefits are provided for home infusion products for the treatment of hemophilia and other bleeding disorders. All services must be prior authorized by Blue Shield and must be provided by a Participat- ing Hemophilia Infusion Provider. (Note: most Participating home health care and home infusion agencies are not Participating Hemophilia Infusion Providers.) To find a Participating Hemophilia In- fusion Provider, consult the Participating Provider directory. Members may also verify this informa- tion by calling Customer Service at the telephone number shown on the last page of this EOC. Hemophilia Infusion Providers offer 24-hour ser- vice and provide prompt home delivery of hemo- philia infusion products. Following Member evaluation by a Doctor of Medicine, a prescription for a blood factor product must be submitted to and approved by Blue Shield. Once prior authorized by Blue Shield, the blood factor product is covered on a regularly scheduled basis (routine prophylaxis) or when a non-emer- gency injury or bleeding episode occurs. (Emer- gencies will be covered as describ...
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 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.
