Three-tier drugs 280.187 012007.vp

Three-tier Pre scrip tion Drug Ben e fits Rider Your Cer tif i cate of Cov er age is amended as ma te ri als in clud ing home glu cose test ing de scribed in this doc u ment. This Rider be - comes a part of your Cer tif i cate of Cov er age and is sub ject to all pro vi sions of your Con tract. This If your cov er age has a pre scrip tion drug ben - Rider re places all Out pa tient Pre scrip tion Drug e fit limit, ben e fits for in su lin and other sup plies ben e fits, if any, de scribed in your Con tract.
for people with di a be tes are not ap plied to thelimit.
1. Covered Ser vices
change and will be up dated from time to time.
The Chapter in your Cer tif i cate en ti tled We will inform you of changes using news let - Covered Ser vices is hereby amended by adding ters and other mail ings. To get the most the fol low ing Covered Ser vice if it is not in your up-to-date list ing, you may visit our web site at Cer tif i cate, or re plac ing any Pre scrip tion Drug www.bcbsvt.com or call cus tomer ser vice at Covered Ser vices al ready in cluded in your the number on the back of your I.D. card.
Limitations
Prescription Drugs
■ pre scribed fer til ity drugs to up to four cy - Net work mail order phar macy to re ceive ben e - cles of fer til ity drug ther apy per cal en dar fits. To locate a Net work Phar macy, go to year re gard less of the num ber of med i ca - www.bcbsvt.com/pages/FindaDoctor.htm.
tions pre scribed (note: this four-cy cle lim - We pro vide ben e fits for Out pa tient use of: i ta tion does not ap ply to clomophine); ■ Pre scrip tion Drugs (in clud ing con tra cep - tive drugs and de vices that re quire a pre - ■ pre scribed smok ing ces sa tion drugs to a s c r i p ti o n ) i f t h e Fo o d a n d D r u g three-month sup ply per cal en dar year.
Ad min is tra tion ap proves them for the We re quire Prior Ap proval for the fol low ing treat ment of your con di tion and you pur - ■ Growth Hor mone Re place ment Ther apy ■ in su lin and other sup plies for peo ple with di a be tes (urine and blood sugar test ing ■ med i ca tions with out a Na tional Drug ■ drugs that have been on the mar ket less How to Get Prior Ap proval for Your Drugs
To get Prior Ap proval for your pre scrip tion drug, your pro vider must write to our med i cal ser vices de part ment with the fol low ing ■ clin i cal in for ma tion ex plain ing the med i - cal ne ces sity for the med i ca tion; and ■ the ex pected fre quency and du ra tion of ■ Low Mo lec u lar Weight Hep a rin An ti co - ag u lants (if used lon ger than 30 days per The list of drugs that need Prior Ap proval changes from time to time. We will inform you of changes using news let ters and other mail -ings. Check with your doctor or visit our web site at www.bcbsvt.com to see if a spe cific drug needs Prior Ap proval. You may also call our cus - tomer ser vice de part ment at the number on Pay ment Terms
Please refer to your Out line of Cov er age to de - ter mine the spe cific pay ment re quire ments ofyour pre scrip tion drug ben e fit. You may have a De duct ible, Coinsurance and/or Co-pay ments You have three levels of Co-pay ments and/or Coinsurance for drugs you pur chase at a phar - ■ P r i m a r y P u l m o n a r y H y p e r t e n s i o n macy or through the mail order phar macy pro - ■ your cost is low est when you use ge neric ■ your cost is higher when you use drugs on Your Coinsurance per cent age will be cal cu - lated on the total cost of the drug, minus any Com pound ing Pre scrip tions
Phar ma cists must some times pre pare med i - We cover up to a 90-day supply for each refill.
cines from raw in gre di ents by hand. This is Nar cot ics, an ti bi ot ics and com pound drugs called com pound ing pre scrip tions. The phar - (see below) are lim ited to a 30-day supply.
ma cist sub mits a claim using the Na tional Drug Mail Or der Pro gram
Code (NDC) for the most ex pen sive legend Our mail order phar macy ser vice can pro vide you with drugs you take on an on go ing basis.
Your cost de pends on the NDC sub mit ted for To obtain pre scrip tions through the mail order ser vice, you must com plete and send a pa tient ■ if the NDC is a ge neric drug, you pay the pro file to our net work mail order com pany t h e g e n e r i c d r u g C o - p ay m e n t o r along with your pre scrip tion. Drugs are de liv - ered to your home ad dress, and you can order ■ if the NDC is a Pre ferred brand-name re fills by phone, fax or on the internet. For more in for ma tion about our mail order phar macy, see the IPS Phar macy Bro chure in cluded in ■ if the NDC is a Non-pre ferred brand-name your mem ber ship packet, or call our cus tomer ser vice de part ment at the number on the back ■ if the NDC is for a pow der or crys tal, you Co-pay ment
pay the Non-pre ferred Co-pay ment orCoinsurance.
A Co-pay ment is a fixed dollar amount that you must pay for spe cific ser vices. Your Out line Exclusions
of Cov er age lists your Co-pay ment amounts.
We pro vide no pre scrip tion drug ben e fits for: 30-day supply. You pay two Co-pay ments for a ■ re fills be yond one year from the orig i nal 90-day supply of a drug when you use the mailorder phar macy or a retail phar macy that ■ de vices of any type other than pre scrip - agrees to accept the same re im burse ment as our mail order phar macy. (Not all retail phar - de vices may re quire a pre scrip tion or der ma cies par tic i pate in this pro gram.) in clud ing, but not lim ited to: Du ra bleMed i cal Equip ment, pros thetic de vices, Coinsurance
ap pli ances and sup ports (al though ben e - Coinsurance is a per cent age of the total drug fits may be pro vided un der other sec tions cost that you must pay. Your Out line of Cov er - age lists your Coinsurance amounts. ■ vi ta mins, ex cept those which, by law, re - 3. Def i ni tions
■ drugs that do not re quire a prescription, Pre scrip tion Drugs: in su lin and drugs that ex cept in su lin, even if your doc tor pre - are:scribes or rec om mends them; and ■ pre scribed by a Phy si cian for a med i cal ■ nu tri tional for mu lae, ex cept for up to $2,500 per year for “med i cal foods” pre - scribed for the Medically Nec es sary treat - ■ ap proved by us for re im burse ment for ment of an in her ited met a bolic dis ease or the spe cific med i cal con di tion be ing treated or di ag nosed, or as oth er wise re - 2. Claim Fil ing
Network Pharmacy
A Net work Phar macy will col lect the amount you owe (De duct ible, Co-payment and/orCoinsurance) and submit claims on your behalf. Wil liam R. Milnes, Jr.
We will re im burse Net work Phar macies di - Pres i dent rectly. You must use a Net work Phar macy or our Net work mail order phar macy to re ceiveben e fits.

Source: http://brsu.org/files/Three-tier%20Drugs%20280.187%20012007.pdf