Outpatient Prescription Drug Benefit. Subject to the terms and conditions of this Section, bene- fits are provided for outpatient prescription Drugs, which are prescribed by a licensed Physician and are obtained from a Participating Pharmacy. Benefits are provided for Formulary Drugs, which are Drugs listed on Blue Shield’s Drug Formulary. This Formulary is updated on a periodic basis by Blue Shield’s Pharmacy and Thera- peutics Committee. Benefits may also be provided for Non-Formulary Drugs subject to higher Copayments. Select Drugs and Drug dosages and most Home Self- Administered Injectables require prior authorization by Blue Shield of California for Medical Necessity appro- priateness of therapy or when effective, lower cost alter- natives are available. Your Physician may request prior authorization from Blue Shield. Coverage for selected Drugs may be limited to a specific quantity as described in the section entitled Limitation on Quantity of Drugs that May be Obtained per Prescription or Refill.
Outpatient Prescription Drug Benefit. Medically Necessary outpatient prescription drugs and insulin are covered when prescribed by a Provider licensed to prescribe federal legend prescription drugs or medicines subject to the terms, HMO policies, Exclusions and Limitations section described in this rider and the EOC. Coverage is based on HMO’s determination that a prescription drug is Medically Necessary. Some items are covered only with Precertification from HMO. Items covered by this rider are subject to drug utilization review by HMO and/or Member’s Participating Provider and/or Member’s Participating Retail or Mail Order Pharmacy. Non-emergency and non-Urgent Care prescriptions will be covered only when filled at a Participating Retail Pharmacy or the Participating Mail Order Pharmacy. Members are required to present their ID card at the time the prescription is filled and pay the applicable Copayment. Members who have lost or misplaced their ID Card may call Member Services at 0- 000-000-0000 for a replacement card and for pharmacy authorizations. A Member who fails to identify themselves as covered by presenting the ID card, or requesting that the Participating Retail Pharmacy contact HMO for verification of coverage will not receive reimbursement for the entire amount of out-of-pocket expenses. HMO will deduct any applicable Copayments, and will reimburse the member for the Contracted Rate for the prescription. Please refer to the EOC for a description of emergency and Urgent Care coverage. HMO retains the right to review all requests for reimbursement and make reimbursement determinations subject to the Claim Procedures/Complaints and Appeals section of the EOC. Precertification: Certain prescription drugs on the Precertification List are covered only when Precertified by HMO. Member’s Participating Physician or Participating Retail or Mail Order Pharmacy (for certain antibiotics) may request Precertification to obtain coverage for drugs on the Precertification List. Prescription drugs on the Step Therapy Program list will be covered if Member’s prescribing Provider requests Prior Authorization. Such Precertification or Prior Authorization requests shall be made by the Provider to the precertification department of HMO’s Pharmacy Management Department. The Pharmacy Management Department will respond to complete Precertification/Prior Authorization requests within 24 hours of receipt, based upon the nature of the member’s medical condition. Coverage granted as a result of Precertificati...
