MEDICAL PRESCRIPTION DRUGS are prescription drugs that require administration (or the FDA approved recommendation is for administration) by a licensed healthcare provider (other than a pharmacist). These medical prescription drugs include, but are not limited to, medications administered by infusion, injection, or inhalation, as well as nasal, topical or transdermal administered medications. Medical prescription drugs are covered as a medical benefit. MEDICALLY NECESSARY (MEDICAL NECESSITY) means that the healthcare services provided to treat your illness or injury, upon review by BCBSRI are: • appropriate and effective for the diagnosis, treatment, or care of the condition, disease, ailment or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of medical practice within the medical community or scientific evidence; • not primarily for the convenience of the member, the member’s family or provider of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, supplies or level of service, which can safely be provided to the member (i.e. no less expensive professionally acceptable alternative, is available). We will make a determination whether a healthcare service is medically necessary. You have the right to appeal our determination or to take legal action as described in Section
