Three-Tier Prescription Drug Benefit Rider A
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1 Three-Tier Prescription Drug Benefit Rider A Your Certificate of Coverage is amended as described in this document. This Rider becomes a part of your Certificate of Coverage and is subject to all provisions of your Contract. This Rider replaces all Outpatient Prescription Drug Benefits, if any, described in your Contract. 1. Covered Services The Chapter in your Certificate entitled Covered Services is hereby amended by adding the following Covered Service: Prescription Drugs You must use a Network retail or mail order Pharmacy to receive Benefits. To locate a Network Pharmacy, visit our website at and click on the Find A Doctor link. We provide Benefits for Outpatient use of: 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; insulin and other supplies for people with diabetes (blood sugar testing materials including home glucose testing machines); and needles and syringes. If your Provider determines that you should not take a generic drug (lowest-tier drug) then your payment responsibility for a brand drug, formulary or nonformulary, can be no greater than the amount that you would have paid for the lowest-tier Co-payment or Coinsurance. Benefits are subject to the exclusions listed in this Rider and General Exclusions in your Certificate of Coverage. Our Preferred Brand-name Drug List can change and will be updated from time to time. We will inform you of changes using newsletters and other mailings. To get the most up-to-date listing, you may visit our website at or call the Pharmacy number on the back of your ID Card. Limitations We Cover up to a 90-day supply for each refill. Narcotics, antibiotics, Specialty Medications, Covered over-the-counter products and compound drugs (see below) are limited to a 30 day supply. We limit Benefits for: Viagra to six pills per month; Cialis to six pills per month; Levitra to six pills per month; prescribed fertility drugs to up to four cycles of fertility drug therapy per calendar year regardless of the number of medications prescribed (note: this four-cycle limitation does not apply to clomophine); prescribed smoking cessation drugs to a three month supply per calendar year; and Tamiflu to 10 capsules per 6 months. Prior Approval Program Our Prior Approval drug list changes from time to time. Visit our website at for the most current list. We will inform you of changes using newsletters and other mailings. We require Prior Approval for the following Prescription Drugs: Drugs that Require Prior Approval Accretropin Amevive Antagon Apokyn Aranesp Arixtra Avastin Avonex Baraclude The Vermont Health Plan An independent licensee of the Blue Cross and Blue Shield Association The Vermont Health Plan 1
2 Betaseron Botox/Myobloc Bravelle Byetta Bystolic Cetrotide Cimzia Copaxone Copegus Emend Enbrel Epogen Erbitux Fertinex Flolan Follistim Fragmin Genotropin Gleevec GnRHa Gonal-FRFP Hepsera Humatrope Humira Innohep Iressa Kineret Lamisil Letairis Lovenox Luveris Meridia Nexavar Norditropin Novarel Nutropin Nutropin AQ Omnitrope Ovidrel Orencia Pegasys Peg-Intron Pergonal Procrit Pregnyl Profasi Protropin Rebetol Rebif Remicade Retin-A (for members over age 41) Repronex Revatio Revlimid Rituxan Saizen Serostim Soliris Somatrem Somatropin Spiriva Sporanox/Itraconazole Sprycel Sutent Symbicort Synarel Tarceva Tekturna Temodar Tev-tropin Tracleer Transmucosal Fentanyl (Actiq & Fentora) Treximet Tykerb Tysabri Valtropin 2 Three-tier Prescription Drug Benefit Rider A
3 Ventavis Vidaza Vyvanse Xolair Xenical Zolinza Zorbtive Zyvox Compounded Medications Dispense as written (Brand-name drugs with generics available) Medications without an NDC number Medications on the market less than 12 months Quantity Limits We will review certain Prescription Drugs for Medical Necessity if the amount of a drug your doctor has prescribed exceeds TVHP quantity limits. TVHP quantity limits affect your Benefit levels; if your doctor determines that you need more than our limit, you may choose to purchase the remainder yourself. Sign on to our member website at 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, follow the steps for Prior Approval to have your prescription reviewed. Our quantity limits drug list changes from time to time. Visit our website at for the most current list. We will inform you of changes using newsletters and other mailings. We limit the quantity of the following drugs: Sleeping Agents Ambien/Ambien CR (Zolpidem) Dalmane Doral Estazolam Flurazepam Halcion Lunesta Placidyl Prosom Restoril Rozerem Sonata Temazepam Pain Medications Actiq Duragesic Fentora Narcotic analgesics containing acetaminophen Oxycontin Toradol (Ketoralac) Triptans Amerge Axert Frova Imitrex Imitrex (nasal spray, injectable, refill kit) Maxalt Maxalt MLT Relpax Stadol nasal spray Zomig Zomig (ZMT and nasal spray) Test Strips Diabetic/Glucose Test Strips Inhalers Advair Aerobid Albuterol Asmanex Atrovent Azmacort Beconase AQ Combivent Foradil Flonase Flovent Intal Maxair Nasonex Nasacort Three-tier Prescription Drug Benefit Rider A 3
4 Nasarel Omnaris Proventil HFA Pulmicort Inhaler Pulmicort Respules Rhinocort AQ Qvar Serevent Spiriva Tilade Ventolin HFA Veramyst Anti-emetics Anzemet Emend Kytril Zofran Anti-fungals Diflucan 150 mg tabs (only) Injections Epipen Other Januvia Lyrica 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 or call 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 for the most current list. We will inform you of changes using newsletters and other mailings. If you engage in step therapy and your doctor concludes that you need to take a brand-name drug instead of a generic, you will pay the Co-payment usually required for generic drugs when you buy the brandname drug. We require Prior Approval for the following Prescription Drugs if we have no information indicating you first tried a generic drug or Covered over-the-counter drug: Selective Serotonin Reuptake Inhibitors Cymbalta Effexor XR Lexapro Prozac Weekly Pristiq Non Sedating Anti Histamines Allegra Clarinex Xyzal Zyrtec COX-2 Inhibitors Celebrex Proton Pump Inhibitors Aciphex Kapidex Nexium Pantoprazole Prevacid Prilosec Protonix Zegerid Angiotensin Receptor Blockers Atacand/Atacand HCT Avalide/Avapro Azor Benicar/Benicar HCT Cozaar/Hyzaar Diovan/Diovan HCT Exforge Micardis/Micardis HCT Teveten/Teveten HCT HMG-CoA Reductase Inhibitors (Statins) Advicor Altoprev 4 Three-tier Prescription Drug Benefit Rider A
5 Caduet Lipitor 10mg and 20mg Vytorin Sedative (Hypnotics) Ambien CR Lunesta Rozerem Intranasal Steroids Agents Beconase AQ Nasacort AQ Omnaris Rhinocort Aqua Veramyst Osteoporosis Agents Actonel Actonel with Calcium Fosamax D Boniva Antiviral Agents Famciclovir Valtrex How to Get Prior Approval for Your Drugs To get Prior Approval for your prescription drug, your Provider must submit the following information to our medical services department or its designee: your name; your diagnosis; your ID number; clinical information explaining the medical necessity for the medication; and the expected frequency and duration of the medication. 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 of Coverage for instructions on how to appeal our decision. 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 mailings. Check with your doctor or visit our website at www. bcbsvt.com to see if a specific drug needs Prior Approval or other review. You may also call call the Pharmacy phone number on the back of your ID Card. Payment Terms Please refer to your Outline of Coverage to determine the specific payment requirements of your prescription drug benefit. You may have a Deductible, 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 Network Pharmacy or through the mail order Pharmacy. In general: your cost is lowest when you use generic drugs; 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 drugs that are not on our Preferred Brand name Drug List. If you engage in step therapy (see page 4) and your doctor concludes that you need to take a brand-name drug instead of a generic, you will pay the Co-payment usually required for generic drugs when you buy the brand-name drug. We cover up to a 90-day supply for each refill. Narcotics, antibiotics, Specialty Medications, Covered over-the-counter products and compound drugs are limited to a 30-day supply. Mail Order Pharmacy The mail order pharmacy can provide you with drugs you take on an ongoing basis. To obtain prescriptions through the mail order Pharmacy, you must complete and send a mail order form and submit it along with your prescription. Drugs are delivered to your home address, and you can order refills by phone, mail or on the Internet. For more information about the mail order Pharmacy, call the Pharmacy phone number on the back of your ID Card. If you use the mail order Pharmacy for your prescriptions, you may save money. A 90-day supply by mail order costs you: the same amount as a 30-day supply at a retail Pharmacy when you use generic drugs: Three-tier Prescription Drug Benefit Rider A 5
6 Twice the amount for a 30-day supply at a retail pharmacy when you use Preferred Brand-name drugs; and Two and one half times the amount you d pay at a retail Pharmacy for a 30-day supply when you use Non-preferred Brand-name drugs. Compounded Prescriptions Pharmacists must sometimes prepare medicines from raw ingredients by hand. This is called compounding prescriptions. The Pharmacist submits a claim using the National Drug Code (NDC) for the most expensive legend ingredient. Your cost depends on the NDC submitted for the compounded drug: if the NDC is a generic drug, you pay the generic drug Co-payment or Coinsurance; if the NDC is a Preferred Brand-name drug, you pay the Preferred Brandname Co payment or Coinsurance; if the NDC is a Non-preferred Brand-name drug, you pay the Non-preferred Brandname Co-payment or Coinsurance; if the NDC is for a powder or crystal, you pay the Non-preferred Co-payment or Coinsurance. Exclusions We provide no prescription drug Benefits for: refills beyond one year from the original prescription date; replacement of Prescription Drugs that are lost, destroyed or stolen; devices of any type other than prescription contraceptives, even though such devices may require a prescription including, but not limited to: Durable Medical Equipment, prosthetic devices, appliances and supports (although Benefits may be provided under other sections of your Contract); any drug considered to be Experimental or Investigational (see definition in Section 3 on this page); vitamins, except those which, by law, require a prescription; drugs that do not require a prescription, except insulin and Covered over-thecounter products, even if your doctor prescribes or recommends them; and nutritional formulae, except for up to $2,500 per year for Covered medical foods prescribed for the Medically Necessary treatment of an inherited metabolic disease or those administered through a feeding tube. 2. Claim Filing Network Pharmacy You must use a Network Pharmacy or our Network mail order Pharmacy to receive Benefits. A Network Pharmacy will collect the amount you owe (Deductible, Co-payment and/or Coinsurance) and submit claims on your behalf. We will reimburse Network Pharmacies directly. However, if you need to be reimbursed, attach itemized bills for the dispensed drugs to a Prescription Reimbursement Form. Contact the Pharmacy number on the back of your ID Card for assistance. 3. Definitions Specialty Medications: injectable and non-injectable drugs with key characteristics, including: frequent dosing adjustments and intensive clinical monitoring; intensive patient training and compliance assistance; limited product availability, specialized product handling and administration requirements. Don C. George President and CEO 6 Three-tier Prescription Drug Benefit Rider A
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