Day Supply. Benefits for covered drugs obtained from a Participating Pharmacy are provided up to the maximum day supply limit as shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. HMO has the right to determine the day supply. Payment for benefits covered by HMO may be denied if drugs are dispensed or delivered in a manner intended to change, or having the effect of changing or circumventing, the stated maximum day supply limitation. If You are leaving the country or need an extended supply of medications, call customer service at least two weeks before You intend to leave. Extended supplies or vacation override are not available through the mail- order program, but may be approved through the retail Pharmacy only. In some cases, You may be asked to provide proof of continued membership eligibility under the Certificate.
Day Supply. In order to be eligible for coverage under this Certificate, the prescribed day sup ply must be medically necessary and must not exceed the maximum day supply limitation described in this Certificate. The Plan has the right to determine the day supply. Payment for benefits covered under this benefit section may be denied if drugs are dispensed or delivered in a manner intended to change, or having the effect of changing or circumventing, the stated maximum day supply limitation. Specialty Drugs are limited to a 30 day supply. For information on these drugs call the customer service toll-free number located on your identification card. However, early prescription refills of topical eye medication used to treat a chron ic condition of the eye will be eligible for coverage after at least 75% of the predicted days of use and the early refills requested do not exceed the total number of refills prescribed by the prescribing Physician or Optometrist. Benefits for pre scription inhalants will not be restricted on the number of days before an inhaler refill may be obtained. However, you may receive coverage for up to a 12‐month supply for dispensed contraceptive drugs and products that are covered under this Benefit Section. For additional information about early refills, please see the Pre scription Refills provision below.
Day Supply. Benefits for Covered Drugs are provided up to the maximum day supply limit as indicated on your Sched- ule Page. The Coinsurance Amounts applicable for the designated day supply of dispensed drugs are also indicated on your Schedule Page. Blue Cross and Blue Shield has the right to determine the day supply at its discretion. Payment for benefits covered under this Policy may be denied if drugs are dispensed or deliv- ered in a manner intended to change, or having the effect of changing or circumventing, the stated maxi- mum day supply limitation. Quantity Versus Time Limit Benefits will be provided for prescription drugs dispensed in the following quantities: S Retail Pharmacy and Specialty Pharmacy - Up to a 30- day supply or 120 units (e.g. pills), whichever is less, for ”non- maintenance” and Specialty Drugs; S Mail- Order Pharmacy - Up to a 90- day supply or 360 units (e.g. pills), which- ever is less, for nitroglycerin, natural thyroid products, and other drugs desig- nated by Blue Cross and Blue Shield as ”maintenance” Legend Drugs. Benefits are not provided under this Policy for charges for prescription drugs dispensed in excess of the above stated amounts. If you are leaving the country or need an extended supply of medication, call Customer Service at least two weeks before you intend to leave. (Extended supplies or vacation override are not available through the mail- order Pharmacy but may be approved through the retail Pharmacy only. In some cases, you may be asked to provide proof of continued enrollment eligibility under the retail Pharmacy.) Prescription Drug Preauthorization Process Blue Cross and Blue Shield has designated certain drugs which require prior approval (preauthorize) in order for benefits to be available under this Policy. Preauthorization helps to assure that your Prescription Drug meets Blue Cross and Blue Shield’s guidelines for Medical Necessity for the condition being treated. A form of preauthorization is our Step Therapy program - a ”step” approach to providing benefits for cer- tain medications your Health Care Practitioner prescribes for you. This means that you may first need to try one or more ”prerequisite” medications before certain high- cost medications are approved for coverage under Outpatient Prescription Drugs. If your Health Care Practitioner prescribes a drug requiring prior approval, you may obtain your prescrip- tion from a Participating Pharmacy by following one of the following steps:
Day Supply. Benefits for covered drugs obtained from a Participating Pharmacy are provided up to the maximum day supply limit as shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. HMO has the right to determine the day supply. Payment for benefits covered by HMO may be denied if drugs are dispensed or delivered in a manner intended to change, or having the effect of changing or circumventing, the stated maximum day supply limitation. If You are leaving the country or need an extended supply of medications, call customer service at least two weeks before You intend to leave. Extended supplies or vacation override are not available through the mail- order program, but may be approved through the retail Pharmacy only. In some cases, You may be asked to provide proof of continued membership eligibility under the Certificate. Dispensing/Quantity Versus Time Limits. The maximum quantity of a given prescription drug indicates the number of units to be dispensed and is determined based on pertinent medical information and clinical efficacy and safety. Quantities of some drugs are restricted regardless of the quantity ordered by the Health Care Practitioner. To determine if a specific drug is subject to this limitation, You may access the website at xxx.xxxxxx.xxx or contact customer service at the toll- free number on Your identification card. If a Prescription Order is written for a certain quantity of medication to be taken in a time period directed by a Health Care Practitioner, the Prescription Order will only be covered for a clinically appropriate pre- determined quantity of medication for the specified amount of time. Dispensing limits are based upon FDA dosing recommendations and nationally recognized clinical guidelines. Sample If You require a Prescription Order in excess of the dispensing limit established by HMO, ask Your Health Care Practitioner to submit a request for clinical review on Your behalf. The Health Care Practitioner can obtain an override request form by accessing our website at xxx.xxxxxx.xxx/xxxxxxxx. Any pertinent medical information along with the completed form should be faxed to Clinical Pharmacy Programs at the fax number indicated on the form. The request will be approved or denied after evaluation of the submitted clinical information. HMO has the right to determine dispensing limits at its sole discretion. Payment for benefits covered by HMO may be denied if drugs are dispensed or delivered in a manner intended to change, or having the...
