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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.

Source: http://www.bcbsvt-secure.com/wps/wcm/connect/5122c1b2-c9e2-4909-97ac-453fbb1e8db8/BCBSVT+3-tier+Drug+280_187.pdf?MOD=AJPERES

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