Outpatient Prescription Drugs Sample Clauses

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: a. Prescription Drugs including Specialty Prescription Drugs obtained from a retail Participating Pharmacy Provider or through a mail service program from a Designated Mail-Order Pharmacy Provider; and b. Selected Prescription Drugs within, but not limited to, the following drug classifications only when such drugs are Covered Medications and when dispensed through an Exclusive Pharmacy Provider: i) Oncology related therapies; ii) Interferons;

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. ▇▇▇▇, S.C., ▇▇▇▇▇▇▇, ▇.▇., and ▇▇▇▇▇, ▇.▇. (2011). Implications of the Accuracy of MEPS Prescription Drug Data for Health Services Research. Inquiry 48(3).

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: a. Prescription Drugs, including Specialty Prescription Drugs, obtained from a retail Participating Pharmacy Provider or through a mail service program from a Designated Mail-Order Pharmacy Provider; and b. Selected Prescription Drugs within, but not limited to, the following drug classifications only when such drugs are Covered Medications and when dispensed through an Exclusive Pharmacy Provider: i) Oncology related therapies; ii) Interferons; iii) Agents for multiple sclerosis and neurological related therapies; iv) Antiarthritic therapies; v) Anticoagulants; vi) Hematinic agents; vii) Immunomodulators; and viii) Growth hormones. These selected Prescription Drugs may be ordered by a Physician or other health care Provider on behalf of the Member or the Member may submit the Prescription Order directly to the Exclusive Pharmacy Provider. In either situation, the Exclusive Pharmacy Provider will deliver the Prescription Drug to the Member

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 ο Most Specialty Drugs, including self-injectable drugs and hemophilia factors, must have Prior Authorization through the Prescription Drugs benefit and may need to be dispensed through the specialty pharmacy vendor. Please refer to the Essential Drug List to identify which drugs require Prior Authorization. Urgent or emergent drugs that are Medically Necessary to begin immediately may be obtained at a retail pharmacy. ο Other Prescription Drugs, as indicated in the Essential Drug List, may require Prior Authorization. Refer to the Essential Drug List to identify which drugs require Prior Authorization.

Outpatient Prescription Drugs. If you require certain Pharmaceutical Products, including specialty Pharmaceutical Products, we may direct you to a Designated Dispensing Entity. Such Dispensing Entities may include an outpatient pharmacy, specialty pharmacy, Home Health Agency provider, Hospital-affiliated pharmacy or hemophilia treatment center contracted pharmacy. If you/your provider are directed to a Designated Dispensing Entity and you/your provider choose not to get your Pharmaceutical Product from a Designated Dispensing Entity, Benefits are not available for that Pharmaceutical Product, unless the provider or its intermediary agrees in writing to accept reimbursement, including copayment, at the same rate as a Designated Dispensing Entity. Certain Pharmaceutical Products are subject to step therapy requirements. This means that in order to receive Benefits for such Pharmaceutical Products, you must use a different Pharmaceutical Product and/or prescription drug product first. You may find out whether a particular Pharmaceutical Product is subject to step therapy requirements by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. A step therapy requirement may not be imposed if: • The step therapy drug has not been approved by the U.S. Food and Drug Administration (FDA) for the medical condition being treated; or • The prescribing provider provides supporting medical information to us that a Prescription Drug Product: ▪ Was ordered by a prescribing provider for the Covered Person within the past 180 days; and ▪ Based on the professional judgment of the prescribing provider, was effective in treating the Covered Person’s medical condition. • The prescription drug has been approved by the FDA and: ▪ Is being used to treat the Covered Person’s stage four advanced metastatic cancer; and ▪ Use of the prescription drug is consistent with the FDA-approved indication or the National Comprehensive Cancer Network Drugs & Biologics Compendium indication for the treatment of stage four advanced metastatic cancer; and ▪ Is supported by peer-reviewed medical literature. We will have certain programs in which you receive an enhanced Benefit based on your actions such as adherence/compliance to medication or treatment regimens and/or participation in health management programs. You can access information on these programs by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card.

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 ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ 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.

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. ▇▇▇▇▇▇▇, ▇.▇., ▇▇▇▇▇▇, ▇., and ▇▇▇▇▇▇, III, ▇.▇. (Eds.). (1999) Informing American Health Care Policy. San Francisco, CA: Jossey-Bass Inc. RTI International (2019). Medical Provider Component (MEPS-MPC) Methodology Report 2017 Data Collection. Rockville, MD. Agency for Healthcare Research and Quality. ▇▇▇▇, B.V., ▇▇▇▇▇▇▇▇, ▇.▇., ▇▇▇▇▇▇, ▇.▇., ▇▇▇▇▇, ▇.▇., ▇▇▇▇▇▇, R.E., ▇▇▇▇▇▇▇, L., ▇▇▇▇▇▇▇▇, S.C., and ▇▇▇▇▇▇▇▇, R. (1996). Technical Manual: Statistical Methods and Algorithms Used in SUDAAN Release 7.0. Research Triangle Park, NC: Research Triangle Institute. ▇▇▇▇▇, ▇.▇., ▇▇▇▇, S.C., and ▇▇▇▇▇▇, 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. 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. 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.