Benefits
|
Retail Pharmacy
|
Mail Service Pharmacy |
Deductible
Per Calendar Year
|
$100 Individual
$300 Family |
Generic
Prescription Drug
|
$5 copayment
|
$10
copayment
|
Brand Formulary
Prescription Drug
|
$10
copayment
|
$20
copayment
|
Brand
Non-Formulary Prescription Drug
|
$20
copayment
|
$40
copayment
|
Days Supply
(per prescription)
|
Up to
30-days
|
Up to
90-days
|
Generic
Substitution
|
When you purchase a brand drug that
has a generic equivalent you will be responsible for the brand drug
copayment plus the difference in cost between the brand and generic
drugs, unless your physician requests that the brand name drug be
dispensed. |
Out of Pocket
Maximum
|
Not Applicable |
Network Pharmacy
|
Pharmacy Files Claim at
Point-of-Sale |
Non-Network
Pharmacy
|
Member Files Claim |
|
Prescription Drug
Categories |
Contraceptives (oral and
injectable)
|
Covered |
Fertility
Agents
|
Covered |
Fluoride
Products
|
Covered |
Insulin and
Diabetic Supplies
|
Covered |
Smoking
Deterrents (prescription)
|
Covered |
Vitamins
(prescription)
|
Covered |
Weight Loss
Drugs
|
Covered |
Allergy
Serum
|
Covered Under Medical Program |
Durable
Medical Equipment
|
Covered Under Medical Program |
Prescription
Hair Growth Products
|
Not Covered |
|
Care Management
Programs |
Quantity Level
Limits on select
prescription drugs
|
Applies – the quantity dispensed
under your plan per new or refill prescription may be limited per
recommended guidelines. |
Managed Rx
Coverage on certain drug
therapies
|
Not Applicable |
Managed Prior
Authorizations on select
prescription drugs
|
Applies only on select prescription
drugs*** |
Customized
* This program
applies to all active employees and annuitants under the age of 65 retired
on or after July 1, 2004
*** Prescription
Drugs that require Prior Authorization: Growth Hormones
This exhibit provides only general information.
More detailed information about benefits and eligibility are contained in
the Plan Document. If there is a difference between this summary and the
Plan Document, the Plan Document will govern.
Prescription Drug Program
Exclusions
Except as specifically provided in the contract or benefit booklet, you are
not covered for the following services, supplies or charges when provided by
a Pharmacy Provider.
1.
Any amounts the member is required to pay directly to the Pharmacy
Provider for each prescription order or refill order.
2.
Charges for a prescription drug when such drug or medication is used
for unlabeled or unapproved indications where such use has not been approved
by the Food and Drug Administration (FDA);
3.
Any drug or medication which is otherwise excluded under the terms of
the Agreement;
4.
Allergy serums provided by a pharmacy provider;
5.
Hair growth stimulants;
6.
Food supplements provided by a pharmacy provider;
7.
Immunizations and biologicals provided by a pharmacy provider;
8.
Any drugs used to abort a pregnancy when provided by a pharmacy
provider;
9.
Any drugs prescribed for cosmetic purposes only;
10.
Any drugs requiring intravenous administration, except insulin and
other injectables used to treat diabetes;
11.
Charges for therapeutic devices or appliances (e.g., support garments
and other non-medicinal substances);
12.
Any drugs that can be purchased without a prescription order;
13.
Any Prescription Drug which is Experimental/Investigational in nature
as determined by Blue Shield in accordance with this Program.
