Participating Pharmacy. When You go to a Participating Pharmacy, You must pay any Copayment and any applicable pricing differences. You may be required to pay for limited or non- Covered Services. No claim forms are required. If You are unsure whether a Pharmacy is a Participating Pharmacy, You may access the website at xxx.xxxxxx.xxx (Provider Finder) or contact customer service at the toll- free number on Your identification card.
Participating Pharmacy. We will only pay for medications prescribed for use outside the hospital. Except in an emergency, the prescription must be written by a participating provider and must be dispensed by a participating pharmacy. Exclusions and Restrictions. Under this section, we will not pay for the following: • Administration or injection of medications; • Replacement of lost or stolen prescriptions; • Medications prescribed for cosmetic reasons, unless they are necessary from a medical point of view. • Experimental medications or medications in research, unless they are recommended by an outside appeals agent; • Medications not approved by the FDA except for a prescribed medication that is approved by the FDA for the treatment of cancer when the medication is prescribed for a ditferent type of cancer than the type for which it was approved by the FDA. Nonetheless, the medication must be recognized for the treatment of the type of cancer for which it was prescribed by one of these publications: – AMA Drug Evaluations – American Hospital Formulary Service – U.S. Pharmacopoeia Drug Information – A review article or editorial comment in a major peer-reviewed professional journal • Nutritional supplements taken optionally; and • Devices and materials of all types, except family planning or birth control devices, basal thermometers, female and male condoms and diaphragms. • Prescribed medications and biological products and the administration of these medications and biological products provided with the intention of causing or helping to cause death, suicide, euthanasia or the compassionate killing of a person. • Medications prescribed for purposes of treating erectile dysfunction.
Participating Pharmacy. We will only pay for prescription drugs prescribed for use outside of a Hospital. Except in an emergency, the prescription must be issued by a Participating Provider and filled at a Participating Pharmacy. Exclusions and Limitations SECTION SEVEN: OTHER COVERED SERVICES Under this Section, we will not pay for the following: • Administration or injection of any drugs. • Replacement of lost or stolen prescriptions. • Prescribed drugs used for cosmetic purposes only. • Experimental or investigational drugs. • Non-FDA approved drugs except that we will pay for a prescription drug that is approved by the FDA for treatment of cancer when the drug is prescribed for a different type of cancer than the type for which the FDA approval was obtained. However, the drug must be recognized for treatment of the type of cancer for which it has been prescribed by one of these publications: - AMA Drug Evaluations; - American Hospital Formulary Service; - U.S. Pharmacopoeia Drug Information; or • A review article or editorial comment in a major peer-reviewed professional journal. • Devices and supplies of any kind, except family planning or contraceptive devices, basal thermometers, male and female condoms, and diaphragms. • Prescribed drugs and biologicals and the administration of these drugs and biologicals that are furnished for the purpose of causing or assisting in causing the death, suicide, euthanasia or mercy killing of a person. • Prescription drugs used for purposes of treating erectile dysfunction. Home Health Care We will pay for up to forty visits per calendar year for home health care provided by a certified home health agency that is a Participating Provider. We will pay for home health care only if you would have to be admitted to a Hospital if home care was not provided. Home care includes one or more of the following services: • Part-time or intermittent home nursing care by or under the supervision of a registered professional nurse; • Part-time or intermittent home health aide services which consist primarily of caring for the patient; • Physical, occupational or speech therapy if provided by the home health agency; and • Medical supplies, drugs and medications prescribed by a physician and laboratory services by or on behalf of a certified home health agency to the extent such items would have been covered if the covered person had been in a Hospital. Preadmission Testing We will pay for preadmission testing when performed at the Hospital where surgery i...
Participating Pharmacy. We will only pay for prescription drugs for use outside of a Hospital. The prescription must be issued by a Participating Provider and filled at a Participating Pharmacy, except in an emergency or where otherwise authorized by Us.
Participating Pharmacy. A Participating Pharmacy is a Pharmacy which has a Participating Pharmacy Agreement in effect with the Pharmacy Benefits Manager at the time services are rendered. Call your local Pharmacy to determine whether it is a Participating Pharmacy or call the toll-free customer service telephone number.
Participating Pharmacy. Any registered, licensed retail pharmacy with whom the pharmacy benefit administrator or We have a contract to dispense Prescription Drugs to Members.
Participating Pharmacy. Any Pharmacy, including a mail order pharmacy, which has entered into a Prepaid Prescription Agreement with Blue Cross and Blue Shield of New Jersey, Inc. or any other Participating Blue Cross Plan indicated by Blues Cross and Blue Shield of New Jersey, Inc.
Participating Pharmacy. Any contract between an insurer and a participating pharmacy or its contracting agency that requires claims to be submitted electronically shall require that payment is to be made electronically to the participating provider or its designee for clean claims submitted electronically or if electronic payment is requested by the provider. Prohibited Provisions
Participating Pharmacy. Present your written prescription from your physician and your Identification Card to the pharmacist at a Participating Pharmacy. The Participating Pharmacy will file your claim for you. You will be charged at the point of purchase for applicable Deductible and/or Copayment or Coinsurance amounts. If you do not present your Identification Card, you will have to pay the full retail price of the prescription. If you do pay the full charge and you believe the Prescription Drug should be covered, ask your pharmacist for an itemized receipt and submit it to us for reimbursement consideration.
