Preventive Contraceptive Methods and Counseling for Women a. See all exclusions.*
Preventive Contraceptive Methods and Counseling for Women. PIC covers preventive contraceptive methods and counseling services received during the calendar year by female members as described in the Preventive Health Care Services Schedule (“Schedule”) and according to the frequency and time frames stated in the Schedule. The Schedule, which includes the preventive contraceptive methods and counseling services for women provided by the Affordable Care Act, is available on PIC’s member website or by calling PIC Customer Service. This coverage includes the full range of Food and Drug Administration approved contraceptive methods for women with reproductive capacity, including women’s contraceptive drugs, devices, and delivery methods obtained from a retail pharmacy, a mail order pharmacy, or received at a provider’s office. Self-administered hormonal contraceptives may be prescribed by a physician, physician assistant, advanced practice registered nurse or a licensed pharmacist. Women’s prescription contraceptives received at a retail pharmacy or mail order pharmacy: • Generic oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. Preferred Brand: 100% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Women’s prescription contraceptives, sterilization procedures, and member education received at a provider’s office: • Generic injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. 100% of eligible charges after the deductible. Not covered. • Sterilization procedures, excluding the reversal of sterilization procedures. 100% of eligible charges. Deductible does not apply. ...
Preventive Contraceptive Methods and Counseling for Women. The full range of Food and Drug Administration approved contraceptive methods for women with reproductive capacity, including women’s contraceptive drugs, devices, and delivery methods obtained from a pharmacy orreceived at a physician’s office: ⮚ Generic oral, injectable, implantable, and insertable contraceptives that require a prescription under applicablelaw; and ⮚ Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicablelaw, and for which no generic alternative exists. • Sterilization procedures, excluding the reversal of sterilization procedures. • Covered person education and counseling about contraceptive methods. 100% of eligible charges. Deductible waived. 80% of eligible charges after the deductible. Skilled Nursing Facility Services – limited to 90 days per benefit period 90% of eligible charges after the deductible. 80% of eligible charges after the deductible. Prescription Drug Services Benefit Schedule Prescription Drug Out-of-Pocket Limit $1,500 per individual per calendar year; $4,500 per family per calendar year For satisfaction of the family out-of-pocket limit, no more than one individual out-of-pocket limit amount will apply for any one individual. After the out-of-pocket limit is satisfied for one individual, other family members’ eligible charges will combine to satisfy the remainder of the family out-of-pocket limit. Covered Services Plan Payment for Retail, Retail/Maintenance and Mail Order Prescription Drugs Tier 1 Drugs Tier 2 Drugs Tier 3 Drugs Plan pays 90% of eligible charges; you pay 10% of eligible charges Plan pays 75% of eligible charges; you pay 25% of eligible charges Plan pays 60% of eligible charges; you pay 40% of eligible charges Specialty Drugs are only covered when obtained through participating Specialty Preferred Pharmacies: • Hy-Vee Pharmacy Solutions • Caremark Specialty Pharmacy
