Clinically equivalent definition
Clinically equivalent means treatments that for most members, will give you similar results for a disease or condition.
Clinically equivalent means drugs that, for most Members, will give You similar results for a disease or condition. If You have questions about whether a certain drug is covered and which drugs fall into this group, please call the number on the back of Your Identification Card, or visit Our website at ▇▇▇.▇▇▇▇▇▇.▇▇▇. • Compound Drugs. Unless otherwise required by law, or is otherwise determined by Anthem to be Medically Necessary. In order for that compound drug to be considered Medically Necessary, the doctor must substantiate to Anthem, in writing, a statement that includes the reasons why use of that compound drug is more medically beneficial than the clinically equivalent alternative. • Contrary to Approved Medical and Professional Standards. Drugs given to You or prescribed in a way that is against approved medical and professional standards of practice. • Delivery Charges. Charges for delivery of Prescription Drugs. • Drugs Given at the Provider’s Office/Facility. Drugs You take at the time and place where You are given them or where the Prescription Order is issued. This includes samples given by a doctor. This exclusion does not apply to drugs used with a diagnostic service, drugs given during chemotherapy in the office as specified in “Therapy Services Outpatient,” or drugs specified in “Medical Supplies, Durable Medical Equipment and Appliances” in the “What is Covered” section they are Covered Services. • Drugs not approved by the FDA. • Drugs over Quantity or Age Limits. Drugs which are over any quantity or age limits set by the Plan or Us. • Drugs over the Quantity Prescribed or Refills After One Year. Drugs in amounts over the quantity prescribed, or for any refill given more than one Year after the date of the original Prescription Order. • Drugs Prescribed by Providers Lacking Qualifications/Registrations/Certifications. Prescription Drugs prescribed by a Provider that does not have the necessary qualifications, registrations and/or certifications as determined by Anthem. • Drugs That Do Not Need a Prescription. Drugs that do not need a Prescription by federal law (including drugs that need a Prescription by State law, but not by federal law), except for injectable insulin. This exclusion does not apply to over-the-counter drugs that We must cover under State or federal law when recommended by the U.S. Preventive Services Task Force and prescribed by a doctor. • Drugs used for Cosmetic Purposes. • Items Covered as Durable Medical Equipment (DME). Therapeutic DM...
Clinically equivalent means treatments that for most Members, will give You similar results for a disease or condition. If You have any questions about the Utilization Review process, the medical policies or clinical guidelines, You may call the Member Service phone number on the back of Your Identification Card. Coverage for or payment of the service or treatment reviewed is not guaranteed even if We decide Your services are Medically Necessary. For benefits to be covered, on the date You get service: