Members may be entitled to Medically Necessary Prescription Drugs depending upon the type of drug; the setting in which the drug is administered, and whether a Prescription Drug Rider is attached to this Policy. This provision sets forth the circumstances in which Prescription Drugs are covered under this Plan.
Inpatient Prescription Drugs: Prescription Drugs, including Specialty Drugs, administered while admitted to an inpatient Facility will be covered as part of a Member's inpatient benefit; and no additional Deductibles, Coinsurance or Copayments are required for Prescription Drugs so administered.
Outpatient Specialty Drugs: Outpatient Prescription Drugs designated on the drug Formulary as Specialty Drugs are covered under this Plan, subject to the outpatient Specialty Drug Copayments and Deductibles indicated in the Schedule of Benefits. Members may contact the Issuer to obtain a copy of the Specialty Drugs appearing on the drug Formulary. Specialty Drugs may require Preauthorization by Our Medical Director. Copayments for Non-Preferred Specialty Drugs will not be considered Out-of-Pocket Expenses for purposes of meeting the Maximum Out of Pocket.
Outpatient Non-Specialty Drugs Administered in Outpatient Setting: Outpatient Prescription Drugs which do not meet the definition of Specialty Drugs, and which are dispensed and administered to a Member in the office of a Participating Provider or in another outpatient setting, will be covered as part of a Member's Medical Benefit; and no additional Copayments are required for outpatient Prescription Drugs so dispensed and administered. Outpatient Prescription Drugs dispensed and administered in an outpatient setting that cost $450 or more for a single dose, and refillable prescriptions whose total cost during a twelve (12) month period could equal or exceed $1,000, may require Preauthorization by the Issuer. Outpatient Prescription Drugs dispensed by a pharmacy and administered in the office of a Participating Provider require approval of the Issuer to be covered as part of the Medical Benefit; without Preauthorization such drugs will be excluded unless covered by a Prescription Drug Rider.
Outpatient Prescription Drugs Exclusions: Unless otherwise covered by a Prescription Drug Rider, this Plan excludes outpatient Prescription Drugs that do not meet the definition of Specialty Drugs, are dispensed at a pharmacy and administered in the office of a Participating Provider or other outpatient setting without prior approval of Our Medical Director, or are not dispensed and administered in the office of a Participating Provider or other outpatient setting.
Determination of Coverage Level: The coverage level of Prescription Drugs under this Plan and any Prescription Drug Rider shall be assigned in the following order: (1) Outpatient Specialty Drug; (2) Prescription Drug administered while admitted in an inpatient setting; (3) Outpatient Prescription Drug that is not a Specialty Drug, administered in the office of a Participating Provider or other outpatient setting; (4) Outpatient Prescription Drug that is not a Specialty Drug and is not administered in the office of a Participating Provider or other outpatient setting, if a Prescription Drug Rider is attached to this Policy. All Prescription Drug coverage is subject to the Exclusions and Limitations provision of this Policy.
Covered Prescription Drugs, Pharmaceuticals and Other Medications: Only Covered Prescription Drugs that may be dispensed following a Prescription Order from a licensed Participating Health Professional and that are prescribed by an authorized provider or filled through a Participating Pharmacy are eligible. The Medical Director may require substitution of a Prescription Drug for another form of Treatment based on Pharmacy & Therapeutics Committee recommendations and cost-effectiveness. Benefits for Medically Necessary drugs for acute, chronic, disabling, or Life-Threatening conditions are available if the drug is FDA approved for at least one indication and is recognized by standard reference compendia or peer-reviewed medical literature. Members are not required to pay more than the lesser of the allowable claim amount, the applicable copayment, or the cash price for the drug.
Formulary Lists: Copayments vary by tier on Our Formulary. Drugs removed from the Formulary during a Member's Plan Year that were on the Formulary at the start of the Plan Year will remain available at the contracted benefit level until the end of the Plan Year. Formulary alternatives, prior authorization, and Preauthorization requirements may apply. Non-formulary drugs may be covered if Medically Necessary, not excluded, and Formulary alternatives are insufficient or clinically inappropriate.
Authorization Requirements: Certain medications may be subject to step therapy, quantity limits, and Preauthorization. Coverage of drugs for stage-four advanced, metastatic cancer will not require prior failure of alternatives when supported by peer-reviewed evidence and FDA approval. Coverage of drugs for Serious Mental Illness for Members age 18+ will not require failure of more than one different drug (excluding generics/equivalents). No more than one Preauthorization per Member annually per drug is required for treatments for autoimmune disease, hemophilia, or Von Willebrand disease with specified exceptions.
Prescription Drug Refill: Refills will not be covered until the Member is reasonably due for a refill based on prescribed dosage and intervals. Specific timing rules apply for chronic eye disease eye-drop refills (not earlier than day 21 for 30-day, day 42 for 60-day, day 63 for 90-day supplies) and other refill parameters.
Maintenance Prescription Drugs: Drugs for chronic conditions designated as maintenance medications are eligible for Medication Synchronization if they meet Preauthorization criteria, are suitable for synchronization, are prescribed with refills, are not Schedule II/III controlled substances, and otherwise qualify.
Copayment, Coinsurance and Deductible: Members must pay the Copayment or Coinsurance for each Prescription Drug as stated in the Schedule of Benefits. Deductibles, Copayments, and Coinsurance for Prescription Drugs are considered Out-of-Pocket Expenses toward the Maximum Out-of-Pocket, unless otherwise stated. Any third-party financial assistance, discounts, or vouchers that reduce a Member's Out-of-Pocket Expenses will be applied to the Member's Deductible, Copayment, Coinsurance, Cost Share, or Maximum Out-of-Pocket when applicable.
Authorization Exceptions: Coverage of certain drugs may be subject to special statutory protections (e.g., stage-four cancer or certain mental health protections) as described above.