Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered
Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $10 - After deductible Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $45 - After deductible Not Covered Tier 3: $70 - After deductible Not Covered Tier 4: $90 - After deductible Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered
Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $10 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $40 Not Covered Tier 3: $70 Not Covered Tier 4: $90 Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay
Preventive Drugs. Benefits for certain preventive care prescription drugs will be as shown in the Summary of Your Costs when received from network pharmacies. Contact Customer Service or visit our web site to inquire about whether a drug is on our preventive care list. You can get a list of covered preventive drugs by calling Customer Service. You can also get this by going to the preventive care list on our web page at xxxxxxx.xxx. Using In-network Pharmacies
Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $7 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $25 Not Covered Tier 3: $40 Not Covered Tier 4: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered by a Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.
Preventive Drugs. Certain outpatient generic drugs are included in the prescription drug benefit and are covered as shown on the Summary of Your Costs. These include drugs required by federal health care reform and certain generic drugs that are taken regularly by a member for disease prevention or to prevent the reoccurrence of a specific disease or condition. Also included is insulin during pregnancy. You can get a list of covered preventive generic drugs by calling Customer Service at the number listed on the back of this contract booklet or by: • Logging into your secure web page at xxxxxxx.xxx and visiting "My Premera Plan" for a list of preventive drugs required by federal health care reform. This list includes drugs such as aspirin, folic acid and certain supplements. These drugs require a prescription and may be limited to a certain age, condition, dosage or type • Logging into your secure web page at xxxxxxx.xxx and going to the pharmacy section for the list of covered generic medications used to lower cholesterol; prevent heart disease; treat a recovered heart attack or stroke victim; and treat diabetes. Pharmacy Management Sometimes benefits for prescription drugs may be limited to one or more of the following: • A specific number of days’ supply or a specific drug or drug dosage appropriate for a usual course of treatment • Certain drugs for a specific diagnosis • Certain drugs from certain pharmacies, or you may need to get prescriptions from an appropriate medical specialist or a specific provider • Step therapy, meaning you must try a generic drug or a specified brand name drug first • Drug synchronization, meaning when a member requests a new prescription to be filled and the cost-sharing adjusted in compliance with state law These limitations are based on medical criteria, the drug maker’s recommendations, and the circumstances of the individual case. They are also based on U.S. Food and Drug Administration guidelines, published medical literature and standard medical references. Dispensing Limits
Preventive Drugs. You can get a list of covered preventive drugs by calling Customer Service at the number listed on the back of this contract booklet or by logging into your secure web page at xxxxxxxxxx.xxx and visiting "My LifeWise Plan" for a list of preventive drugs required by federal health care reform. This list includes drugs such as aspirin, folic acid and certain supplements. These drugs require a prescription and may be limited to a certain age, condition, dosage or type Pharmacy Management Sometimes benefits for prescription drugs may be limited to one or more of the following: A specific number of days’ supply or a specific drug or drug dosage appropriate for a usual course of treatment Certain drugs for a specific diagnosis Certain drugs from certain pharmacies, or you may need to get prescriptions from an appropriate medical specialist or a specific provider Step therapy, meaning you must try a generic drug or a specified brand name drug first Drug synchronization, meaning when a member requests a new prescription to be filled and the cost-sharing adjusted in compliance with state law These limitations are based on medical criteria, the drug maker’s recommendations, and the circumstances of the individual case. They are also based on U.S. Food and Drug Administration guidelines, published medical literature and standard medical references. Dispensing Limits
Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $7 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $35 Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered bya Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.
Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $0 - After deductible Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $0 - After deductible Not Covered Tier 3: $0 - After deductible Not Covered Tier 4: $0 - After deductible Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered bya Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.
Preventive Drugs. When purchased at any pharmacy: Must be prescribed bayphysician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug sectionfor details. When a generic brand (Tier 1) is not available, a preferred brand (Tier 2) will be covered at the Tier level. Tier 1: $0 Not Covered Tier 2: $30 Not Covered Tier 3: $50 Not Covered Tier 4: $75 Not Covered Tier 5: NRT anSdmoking Cessation drugs are only placed in Tier 1, Tier 2, Tie 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Diabetes, Asthma, and COPD Prescription Drugs Membermust be receiving treatment for certain heal conditions.Copaymentapplies per each 3-0day supply or portion thereof of maintenance and -non maintenance prescription drugs. Up to a 90-day supply of maintenance and n-on maintenance prescription drugsaivsailable at certain retail pharmacies. For a 9-d0ay supply; three retail copayments apply. For more information about pharmacies offering this option, visit our website. $2 Not Covered Prescription Drugs Administered by a Provider (other than a Pharmacy). See the Summary of Medic Benefits. See the Summary of Medic Benefits.
