Three-Tier Prescription Drug Benefits Rider
Your Certificate of Coverage is amended as de- you of changes using newsletters and other mailings.
scribed in this document. This Rider becomes a part To get the most up-to-date listing, you may visit our
of your Certificate of Coverage and is subject to website at www.bcbsvt.com or cal the pharmacy
all provisions of your Contract. This Rider replaces phone number on the back of your ID Card.
all Outpatient Prescription Drug benefits, if any, Mail Order Service
The mail order pharmacy can provide you with
1. Covered Services
To obtain prescriptions through the mail order
The Chapter in your Certificate entitled Covered service, you must complete and send a mail order
Services is hereby amended by adding the follow- form and submit it with your prescription. Drugs are
ing Covered Service if it is not in your Certificate or delivered to your home address, and you can order
replacing any Prescription Drug Covered Services refills by phone, fax or on the internet. For more
already included in your Certificate.
information about our mail order service, call the
pharmacy phone number on the back of your ID Card. Prescription Drugs Limitations
You must use a Network Pharmacy or our Network
mail order pharmacy to receive benefits. To locate a
We cover up to a 90-day supply for each refill.
Network Pharmacy, visit our website at www.bcbsvt.
Narcotics, antibiotics, Specialty Medications, covered
com and click on the “Find A Doctor” link. We provide over-the-counter products and compound drugs (see
below) are limited to a 30-day supply.
Prescription Drugs (including contraceptive drugs and devices that require a prescription)
if the Food and Drug Administration approves
them for the treatment of your condition and
you purchase them from a licensed pharmacy;
prescribed fertility drugs to up to four cycles of fertility drug therapy per calendar year
insulin and other supplies for people with diabetes (blood sugar testing materials
including home glucose testing machines); and
prescribed (note: this four-cycle limitation does not apply to clomophine);
Benefits are subject to the exclusions listed in this
rider and General Exclusions in your Certificate of
three-month supply per calendar year; and
Tamiflu to 10 capsules per 6 months.
Our Preferred Brand-name drug list can change
and wil be updated from time to time. We wil inform
Prior Approval Program • Iressa
Our Prior Approval drug list changes from time to
• Kineret
time. Visit our website at www.bcbsvt.com for the most
• Lamisil
current list. We wil inform you of changes using news-
• Letairis
letters and other mailings. We require Prior Approval
• Lovenox • Luveris • Meridia Prior Approval • Nexavar •• Accretropin • Norditropin •• Amevive • Novarel •• Antagon • Nutropin •• Apokyn • Nutropin AQ •• Aranesp • Omnitrope •• Arixtra • Ovidrel •• Avastin • Orencia •• Avonex • Pegasys •• Baraclude • Peg-Intron •• Betaseron • Pergonal •• Botox/Myobloc • Procrit •• Bravelle • Pregnyl •• Byetta • Profasi •• Bystolic • Protropin •• Cetrotide • Rebetol •• Cimzia • Rebif •• Copaxone • Remicade •• Copegus • Retin-A (for members over age 41) •• Emend • Repronex •• Enbrel • Revatio •• Epogen • Revlimid •• Erbitux • Rituxan •• Fertinex • Saizen •• Flolan • Serostim •• Follistim • Soliris •• Fragmin • Somatrem •• Genotropin • Somatropin •• Gleevec • Spiriva •• GnRHa • Sporanox/Itraconazole •• Gonal-FRFP • Sprycel •• Hepsera • Sutent •• Humatrope • Symbicort •• Humira • Synarel •• Innohep •• Tarceva Sleeping Agents •• Tekturna •• Temodar •• Tev-tropin •• Tracleer •• Transmucosal Fentanyl (Actiq & Fentora) •• Treximet •• Tykerb •• Tysabri •• Valtropin •• Ventavis •• Vidaza •• Vyvanse •• Xolair •• Xenical Pain Medications •• Zolinza •• Zorbtive •• Zyvox •• Compounded Medications
Narcotic analgesics containing acetaminophen
•• “Dispense as written” (Brand-name drugs •• Medications on the market less than 12 months Triptans Quantity Limits
We will review certain Prescription Drugs for
Medical Necessity if the amount of a drug your doc-
tor has prescribed exceeds BCBSVT quantity limits.
Imitrex (nasal spray, injectable, refill kit)
Quantity limits affect your benefit levels; if your doc-
tor determines that you need more than our limit, you
may choose to purchase the remainder yourself. Sign
on to our member website at www.bcbsvt.com or call
the pharmacy phone number on the back of your ID
Card to learn the quantity limit for each drug. If the
amount you are prescribed exceeds our limits, fol ow
the steps for Prior Approval to have your prescription Test Strips
reviewed. Our quantity limits drug list changes from
time to time. Visit our website at www.bcbsvt.com for
the most current list. We will inform you of changes Inhalers
using newsletters and other mailings. We limit the
Step Therapy
We review certain Prescription Drugs if you do
not first try a generic drug or covered over-the-
counter drug. Sign on to our member website at
www.bcbsvt.com or cal the pharmacy phone number
on the back of your ID Card to learn the guidelines for
each drug. Our Step Therapy drug list changes from
time to time. Visit our website at www.bcbsvt.com for
the most current list. We wil inform you of changes
using newsletters and other mailings. We require
Prior Approval for the fol owing Prescription Drugs
if we have no information indicating you first tried
a generic drug or covered over-the-counter drug:
Selective Serotonin Reuptake Inhibitors Non Sedating Anti Histamines Anti-emetics COX-2 Inhibitors Proton Pump Inhibitors Anti-fungals Injections Angiotensin Receptor Blockers How to Get Prior Approval for Your Drugs
To get Prior Approval for your prescription drug,
your provider must write to our medical services
department or its designee with the following
clinical information explaining the medical
HMG-CoA Reductase Inhibitors
the expected frequency and duration of the
If you have an emergency or an urgent need for
a drug on our Prior Approval list, call the pharmacy
phone number on the back of your ID Card. If we deny
your request for Prior Approval, see your Certificate
COX-2 Inhibitors
of Coverage for instructions on how to appeal our
Sedative (Hypnotics)
Our quantity limits, step therapy and Prior Approval
drug lists change from time to time. We will inform
you of changes using newsletters and other mail-
ings. Check with your doctor or visit our website
at www.bcbsvt.com to see if a specific drug needs
Intranasal Steroid Agents
Prior Approval or other review. You may also cal the
pharmacy phone number on the back of your ID Card. Payment Terms
Please refer to your Outline of Coverage to de-
termine the specific payment requirements of your
prescription drug benefit. You may have a Deductible,
Osteoporosis Agents
Coinsurance and/or Co-payments for prescription
drugs. We do not apply both Coinsurance and Co-
payments to the same Prescription Drug purchase.
You have three levels of Co-payments and/or
Coinsurance for drugs you purchase at a pharmacy
or through the mail order pharmacy program. In
Antiviral Agents
your cost is lowest when you use generic
your cost is higher when you use drugs on our Preferred Brand-name Drug List; and
your cost is highest when you use brand-name
Exclusions
drugs that are not on our Preferred Brand-
We provide no prescription drug benefits for:
refills beyond one year from the original
We cover up to a 90-day supply for each refill.
Narcotics, antibiotics, covered over-the-counter
replacement of Prescription Drugs that are lost,
products and compound drugs (see below) are lim-
devices of any type other than prescription
Co-payment
contraceptives, even though such devices
A Co-payment is a fixed dollar amount that
may require a prescription including, but
you must pay for specific services. Your Outline of
not limited to: Durable Medical Equipment,
Coverage lists your Co-payment amounts.
prosthetic devices, appliances and supports
You must pay one Co-payment for each 30-day
(although benefits may be provided under
supply. You pay two Co-payments for a 90-day sup-
ply of a drug when you use the mail order pharmacy
any drug considered to be Experimental or
or a retail pharmacy that agrees to accept the same
reimbursement as our mail order pharmacy. (Not all
Investigational (see definition in Section 3 on
vitamins, except those which, by law, require a
Coinsurance
Coinsurance is a percentage of the total drug cost
drugs that do not require a prescription,
that you must pay. Your Outline of Coverage lists your
except insulin and covered over-the-counter
Your Coinsurance percentage wil be calculated
products, even if your doctor prescribes or
on the total cost of the drug, minus any deductible
nutritional formulae, except for up to $2,500 per year for “covered medical foods” prescribed
Compounded Prescriptions
Pharmacists must sometimes prepare medicines
for the Medically Necessary treatment of
from raw ingredients by hand. These medicines are
called compounded prescriptions. The pharmacist
administered through a feeding tube.
submits a claim using the National Drug Code (NDC)
for the most expensive legend ingredient. 2. Claim Filing
Your cost depends on the NDC submitted for the
Network Pharmacy
if the NDC is a generic drug, you pay the
A Network Pharmacy will collect the amount you
owe (Deductible, Co-payment and/or Coinsurance)
and submit claims on your behalf. We wil reimburse
if the NDC is a Preferred Brand-name drug, you pay Preferred Brand-name Co-payment
Network Pharmacies directly. You must use a Network
Pharmacy or our Network mail order pharmacy to
receive benefits. However, if you need to be reim-
if the NDC is a Non-preferred Brand-name
bursed, attach itemized bil s for the dispensed drugs
to a Prescription Reimbursement Form. Contact the
pharmacy number on the back of your ID Card for
if the NDC is for a powder or crystal, you pay
the Non-preferred Co-payment or Coinsurance. 3. Definitions Specialty Medications: injectable and non-
injectable drugs with key characteristics, including:
Experimental or Investigational Services: frequent dosing adjustments and intensive clinical
health care items or services that are either not gen- monitoring; intensive patient training and compliance
eral y accepted by informed health care providers in assistance; limited product availability, specialized
the United States as effective in treating the condition, product handling and administration requirements.
il ness or diagnosis for which their use is proposed, or
are not proven by Medical or Scientific Evidence to be
effective in treating the condition, il ness or diagnosis
for which their use is proposed. Prescription Drugs: insulin and drugs that are:
approved by us for reimbursement for the specific medical condition being treated or diagnosed, or as otherwise required by law.
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3. Definitions