Outpatient Prescription Drug Rider available with Traditional, Deductible, and High Deductible Health Plans that includes a higher cost share for Approved Non-Formulary Drugs has been modified. We have decreased the Member cost share for Approved Non-Formulary Generic Drugs. The Member pays the Generic Drug cost share for both the Generic Formulary and Generic Approved Non- Formulary Drug. The dollar allowances explanation for hearing aids and vision hardware has been changed in the “Hearing Aid Rider” and “Vision Hardware and Optical Services Rider.” The statement that the dollar allowance can be used only at the initial point of sale has been deleted. Language has been changed in certain “Vision Hardware and Optical Services Riders.” The provision that allowed for replacement eyeglass lenses or contact lenses within 12 months was erroneous for 12-month benefit allowance plans. The provision is applicable only to “Vision Hardware and Optical Services Riders” with a 24-month benefit allowance period. The “Outpatient Prescription Drug Rider” that includes the MedImpact pharmacy option is modified. If a Generic Drug is available and the prescribing provider chooses a Brand-Name Drug, the Member is not responsible for paying the cost difference between the Brand-Name Drug and the Generic Drug. Benefit clarifications The “Outpatient Prescription Drug Rider Benefit Summary” Mail Delivery Pharmacy rows have been removed. The information has been incorporated into the Participating Pharmacy rows since the Member cost share for drugs, supplies, or supplements obtained from a Participating Pharmacy and from a Mail Delivery Pharmacy are the same. Note this change does not apply to maintenance drugs. The Added Choice “Outpatient Prescription Drug Rider” that covers Brand-Name and Generic Drugs only if obtained at Select Pharmacies has been modified. The definitions of “Preferred Brand-Name Drug” and “Non-Preferred Brand-Name Drug” have been deleted because the terms are not used elsewhere in the rider. The Added Choice “Outpatient Prescription Drug Rider” that includes the MedImpact pharmacy network option has been modified. The definition of “Approved Non-Formulary Brand-Name or Generic Drug” has been added. Cost-share tiers are now included in the “Outpatient Prescription Drug Rider Benefit Summary” for “Formulary Brand-Name Drugs” and “Approved Non-Formulary Brand- Name Drugs.” These cost-share tiers apply to drugs obtained from Select pharmacies.
Outpatient Prescription Drug Rider has been modified. All references to the medical directory have been updated to “Medical Facility Directory” to reflect the revised definition in the EOC.
Outpatient Prescription Drug Rider used for Traditional, Deductible, and High Deductible Health Plans has been modified. A sentence has been added to the “Copayments and Coinsurance for Covered Drugs and Supplies” section to clarify that prescription drugs and supplies received are subject to the Deductible, Copayment, or Coinsurance until the medical Out-of-Pocket Maximum is met.
Examples of Outpatient Prescription Drug Rider in a sentence
The following are not covered under the Outpatient Prescription Drug Rider.
To find out if a prescription drug is subject to prior authorization or step-therapy requirements, please see Drugs, Supplies and Supplements in Section 3 – Benefits, Exclusions and Limitations or the Benefits section of the Outpatient Prescription Drug Rider, if applicable.
Outpatient Prescription Drug Rider Group Rider HMO/POS Enhanced Rx - Value Formulary $15/30/45 with $250 Pharmacy Deductible Summary of Benefits This Summary of Benefits shows the amount you will pay for covered Drugs under this prescription Drug Benefit.
The Out-of-Pocket Limit applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits, including Covered Health Care Services provided under the Outpatient Prescription Drug Rider, the Pediatric Vision Care Services Rider, and the Pediatric Dental Services Rider.
The Out-of-Pocket Limit applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drug Rider.
More Definitions of Outpatient Prescription Drug Rider
Outpatient Prescription Drug Rider has been modified. A row for self-administered chemotherapy medications used for the treatment of cancer has been added. These medications are subject to the plan’s administered medications benefit up to 20% or at the applicable prescription drug tier, whichever is less. These drugs are not subject to the Deductible except for HSA-qualified plans. Benefit clarifications
Outpatient Prescription Drug Rider used for Added Choice plans has been modified to clarify that drugs and supplies received at MedImpact Pharmacies are subject to the Deductible, Copayment, or Coinsurance until the Tier 1 medical Out-of-Pocket is met. The “About Our Drug Formulary” section of the “Outpatient Prescription Drug Rider” has been modified. The URL to view the drug formulary has been expanded to xx.xxx/xxxxxxxxx for clarity. The “Drug Formulary Exception Process” section of the “Outpatient Prescription Drug Rider” has been modified to clarify that the exception process is also available when any licensed dentist prescribes a drug or supply.
Outpatient Prescription Drug Rider has been modified. Language has been added to the “Day Supply Limit” section to clarify that a Member may receive a three-month supply for a first dispensing of a contraceptive drug and a 12-month supply of a subsequent dispensing of the same drug for better alignment with ORS 743A.066. The “Pediatric Vision Hardware and Optical Services Rider” and the “Adult Vision Hardware and Optical Services Rider” have been modified. The vision therapy exclusion has been updated using clinical language for clarity to state that optometric vision therapy and orthoptics (eye exercises) are excluded. The “Pediatric Vision Hardware and Optical Services Rider” has been modified. The exclusion for professional services for fitting and follow-up care for cosmetic contact lenses has been removed. Contact lens fitting fees may only be excluded for adult Members if the contact lenses are not medically necessary. These fees may not be excluded for pediatric Members who have coverage for vision hardware or for adult Members whose contact lenses are medically necessary. The “Pediatric Vision Hardware and Optical Services Rider” has been modified. The exclusion for glass, non-plastic, and non-polycarbonate lens material has been removed due to OAR 836-053-0013 which requires that pediatric vision coverage must match the Federal Employees Dental and Vision Insurance Program (FEDVIP) plan which covers glass lenses. The “Non-prescription products” bullet in the “Pediatric Vision Hardware and Optical Services Rider Exclusions” section has been modified to include ultraviolet protection coating as an included lens coating and lens tints have been removed as an exclusion due to OAR 836-053-0013 which requires that pediatric vision coverage must match the FEDVIP plan which covers these items. The Eyeglasses and Contact Lenses – Enhanced Benefit row in the “Pediatric Vision Hardware and Optical Services Enhanced Benefit Rider Benefit Summary” has been expanded to indicate that one conventional pair of contact lens or up to a 12-month supply of disposable contact lenses is covered, as industry standard has changed with the development of disposable contact lenses The Medically Necessary contact lenses row in the “Pediatric Vision Hardware and Optical Services Rider Benefit Summary” has been expanded to indicate that one conventional pair of contact lens or up to a 12-month supply of disposable contact lenses is covered, as industry standard has changed with the development of di...
Outpatient Prescription Drug Rider available for Deductible or High Deductible Health Plans has been modified. Language has been added to the formulary contraceptive row in the “Outpatient Prescription Drug Rider Benefit Summary” to clarify that coverage is not subject to any Deductible. The “Outpatient Prescription Drug Rider” has been modified. Language has been added regarding day supply limits to the formulary contraceptive row in the “Outpatient Prescription Drug Rider Benefit Summary” for consistency.
Outpatient Prescription Drug Rider if one has been purchased by the group, or indicate the appropriate Deductible, Copayment, or Coinsurance if not. The Enteral pump and supplies row under “Outpatient Durable Medical Equipment (DME)” in the Benefit Summary has been removed. These Services are no longer covered at $0, they are now covered at the Outpatient Durable Medical Equipment Deductible, Copayment, or Coinsurance. The “Hearing Aid Services for Dependents” section of the EOC has been modified to clarify that we cover hearing aids and hearing assistive technology systems in accordance with state and federal law. Per guidance from the Oregon Department of Financial Regulation (DFR) we have stayed silent on all limits pertaining to hearing aids. Assistive listening devices and batteries have been removed from the “Hearing Aid Services for Dependents Exclusions” section. Members may contact Member Services for more information about hearing aid coverage. The “Hearing Aid Services for Dependents” section of the Benefit Summary has been modified. The language indicating that hearing aids are limited to one hearing aid every 36 months has been removed per guidance from the Oregon Department of Financial Regulation (DFR) that we should stay silent on all limits pertaining to hearing aids. Hearing aids are covered per applicable state and federal law. Members may contact Member Services for more information about hearing aid coverage. Benefit clarifications The “External Prosthetic Devices and Orthotic Devices” row in the Benefit Summary has been split into two separate rows for “External Prosthetic Devices” and “Orthotic Devices.” The Emergency Services Definition has been modified. Language has been added to clarify that patient observation is included as part of a medical screening examination with respect to an Emergency Medical Condition. The definition of Participating Pharmacy in the Traditional, Deductible and High Deductible Health Plan EOCs has been modified to include other pharmacies designated and listed as a Participating Pharmacy in the Medical Directory. The “Coverage, Deductible, Copayments, Coinsurance, and Reimbursement” and “Emergency Services” sections under “Emergency, Post-Stabilization, and Urgent Care” in the EOC have been modified. We clarify that all Services received in the emergency department are subject to the Emergency Services Deductible, Copayment or Coinsurance. The emergency department visit row in the benefit summary has been modified to refle...
Outpatient Prescription Drug Rider has been modified for clarity. A Medication Synchronization section has been added to describe the process for coordinating medication refills when Members are taking two or more medications for a chronic condition. The “Outpatient Prescription Drug Limitations” section of the “Outpatient Prescription Drug Rider” has been modified for clarity. Language has been added describing that quantity limits may be applied to certain drugs or supplies to ensure safe and appropriate use. Members may view drugs or supplies subject to quantity limits on our drug formulary. An “Outpatient Prescription Drug Limitations (Select Pharmacies Only)” section has been added to the “Outpatient Prescription Drug Rider (including MedImpact Pharmacies)” describing quantity limits that may be applied to certain drugs or supplies to ensure safe and appropriate use. Members may view drugs or supplies subject to quantity limits on our drug formulary.
Outpatient Prescription Drug Rider has been modified. Language in the “Covered Drugs and Supplies” section has been added to clarify that over-the-counter contraceptive drugs, devices, and products approved by the FDA, do not require a prescription in order to be covered per ORS 743A.067.