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:
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. 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. 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. Introduction/Prior We provide Benefits for drugs and medicines obtained at a participating Authorization: pharmacy that require a Physician’s prescription. Certain medications or classes of medications may require Prior Authorization. To receive Prior Authorization, Your Physician will need to submit to Us a statement of Medical Necessity. Certain medications are subject to utilization programs that require You to try to use a therapeutic alternative before another medication will be considered a Covered Service. Your Physician may submit to Us a statement of Medical Necessity if the utilization program is not appropriate for Your medical condition. For participating providers, You must always pay the lower of either: (a) Your applicable Prescription Drug Copayment, specified in the Benefit Schedule; or (b) the participating pharmacy’s Usual and Customary Charge if the Usual and Customary Charge is less than Your Copayment. For purposes of this paragraph, Usual and Customary Charge means the amount that the participating pharmacy would have charged You if You were a cash paying customer. Such amount includes all applicable discounts, including, without limitation, senior citizen’s discounts, coupon discounts, non-insurance discounts, or other special discounts offered to attract customers. Drug Rebates and We contract with a pharmacy benefit manager (“PBM”) for certain Credits: prescription drug rebate administration services. Under the agreement, PBM obtains rebates from drug manufacturers based on the utilization of certain branded prescription products by Covered Persons. As partial consideration for these services, pharmaceutical manufacturers pay administrative fees to PBM and PBM retains the benefit of the funds prior to disbursement. Administrative fees retained by PBM in connection with its rebate program do not exceed the greater of (i) 4.58% of the Average Wholesale Price, or (ii) 5.5% of the wholesale acquisition cost of the products. PBM may also receive other service fees from manufacturers as compensation for various services unrelated to rebates or rebate-associated administrative fees. We receive rebates from the PBM and may from time to time receive financial credits, and/or other amounts (collectively “Financial Credits”) from network pharmacies, drug manufacturers, or the PBM. We retain sole and exclusive right to all Financial Credits and may use such Financial Credits in Our sole and absolute discretion (including, for example, to help...
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. F.11.01.
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. Home Infusion and Home Injectable Therapy Benefits 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. Hemophilia Home Infusion Products and Ser- vices 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...
Outpatient Prescription Drugs. Benefits for Medically Necessary Covered Drugs (subject to the Generics Plus Drug List and other limita- tions and exclusions described below) prescribed to treat you for a chronic, disabling, or life- threatening illness are available under the plan if the drug: S Has been approved by the United States Food and Drug Administration (FDA) for at least one indication; and; S Is recognized by the following for treatmentof the indication for which the drug is prescribed a prescription drug reference compendium approved by the Department of Insurance, or substantially accepted peer- reviewed medical literature. As new drugs are approved by the United States Food and Drug Administration (FDA), such drugs, unless the intended use is specifically excluded under the plan, are eligible for benefits. Some equivalent drugs are manufactured under multiple brand names. In such cases, Blue Cross and Blue Shield may limit benefits to only one of the brand equivalents available. Benefits are available for Covered Drugs as indicated on your Schedule Page. YOUR IDENTIFICATION CARD The Identification Card you received is the key to your use of Outpatient Prescription Drugs. It tells Partici- pating Pharmacies that you are entitled to prescription drug benefits under Outpatient Prescription Drugs. Participating Pharmacies are not permitted to file Claims with Blue Cross and Blue Shield unless you pres- ent the Identification Card with your Prescription Order.
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.
