3d9e3688-29c5-4335-bc4e-0ab6d078fcd1.pdf

Retail Program
The retail program provides up to a 34-day
This program is based on the CareFirst BlueCross BlueShield (CareFirst) supply of medication. Simply present your or CareFirst BlueChoice, Inc. (CareFirst BlueChoice) preferred drug prescription drug identification card at a list, which is made up of all generic prescription drugs (Tier 1) and preferred brand name prescription drugs (Tier 2). Your participating physician has a complete copy of the CareFirst or CareFirst BlueChoice preferred drug list. The preferred drug list changes frequently in response to Food and Drug Administration (FDA) requirements. The Mail Order Program
list is also adjusted when a generic drug is introduced for a brand The mail service program is a convenient name drug. When that happens, the generic drug will be added to the Tier 1 list and the brand name drug will move from Tier 2 to Tier 3.
prescription is reviewed and dispensed by registered pharmacists and mailed directly to your home. Call Walgreens Mail Service Talk to your doctor when you are prescribed medications to see if you are using drugs that are on the preferred drug list – these are also Maintenance Drugs
known as Tier 1 or Tier 2 drugs. You will save the most money if you can take those medications. You can get your prescription filled by drugs are available through mail order or using the retail or mail order programs. If you have questions about retail pharmacy at twice the appropriate your coverage, call Argus Health Systems at (800) 241-3371.
copayment for your medications. Maintenance medication is a prescription drug anticipated to be required for 6 months or more to treat a chronic condition. * Injectables = Self-Administered Injectables. Access www.carefirst.com/rx for more information and
for the most up-to-date preferred drug list.
Deductible
Your benefit does not have a deductible.
Family Deductible Maximum
Your benefit does not have a family deductible maximum.
Generic Drugs (Tier 1)
All generic drugs are covered at this copay level.
(up to a 34-day supply)
Preferred Brand Name Drugs (Tier 2) $25
All preferred brand name drugs are covered at this copay level.
(up to a 34-day supply)
Non-Preferred Brand Name Drugs
All non-preferred brand name drugs are covered at this copay level. These drugs are not on the preferred drug list. Check the online preferred drug list to see if there is an alternative drug available. Discuss using alternatives with your physician or pharmacist.
Self-Administered Injectables
All Self-Administered Injectable drugs (excluding insulin) are covered (excluding insulin) (Tier 4)
at this payment level. Insulin is covered at appropriate copay level.
(up to a 34-day supply)
Annual Maximum
Your benefit does not have an annual benefit maximum.
Maintenance Copays
Maintenance drugs of up to a 90-day supply are available for twice the copay through the mail service or retail pharmacy. Injectables (excluding insulin) are covered at 50% coinsurance up to a maximum 50% coinsurance, up to a maximum payment of $150 Generic Substitution
If you choose a non-preferred brand name drug (Tier 3) over its generic equivalent (Tier 1) you will pay the highest copay PLUS the difference in cost between the non-preferred brand name drug and the generic drug up to the cost of the prescription.
Prior Authorization
Some prescription drugs require Prior Authorization. Prior Authorization
is a tool used to ensure that you will achieve the maximum clinical
benefit from the use of specific targeted drugs. Your physician or
pharmacist must call (800) 294-5979 to begin the prior authorization
process. For the most up-to-date prior authorization list, visit the
prescription drug web site at www.carefirst.com/rx.
This plan summary is for comparison purposes only and does not create Policy Form Numbers: VA/CFBC/RX3 (R. 1/04) • VA/CF/RX3 (R. 1/04) •
rights not given through the benefit plan.
VA/CC/DOC 5/01 • PPP-A-1/95 and any amendments.
Did You Know?Q If the cost of your medication is less than your copayment, Q You can use your prescription drug card at more than 59,000 participating pharmacies nationwide.
Q A generic drug is a prescription drug that by law must have Q Frequently asked questions about your prescription the equivalent chemical composition as a specific brand benefits are available at www.carefirst.com/rx.
CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
Below are the limitations and exclusions contained in your
Treatment for obesity except for the surgical treatment of Morbid CareFirst or CareFirst BlueChoice medical policy to which
Medical or surgical treatment of myopia or hyperopia. Coverage is the prescription rider is attached.
not provided for radial keratotomy and any other forms of refractive keratoplasty, or any complications.
Medical Limitations and Exclusions – CareFirst BlueChoice
Services furnished as a result of a referral prohibited by law.
10.1 Coverage Is Not Provided For:
Services solely required or sought on the basis of a court order or Any service, supply or item that is not Medically Necessary. Although as a condition of parole or probation unless authorized or approved a service may be listed as covered, benefits will be provided only if the service is Medically Necessary as determined by the Plan.
Health education classes and self-help programs, other than Services that are Experimental or Investigational as determined by birthing classes or for the treatment of diabetes. Acupuncture services except when approved or authorized by the Any service related to recreational activities. This includes, but is not Are normally furnished without charge to persons without health limited to: sports; games; equestrian; and athletic training. These services are not covered unless authorized or approved by the Plan Would have been furnished without charge if you were not even though they may have therapeutic value or be provided by a covered under this Certificate or under any health insurance.
Services that are not described as covered in this Certificate or that do not meet all other conditions and criteria for coverage, as Any service received at no charge to the Member in any federal determined by the Plan. Referral by a Primary Care Physician and/ hospital or facility, or through any federal, state, or local or the provision of services by a Plan Provider does not, by itself, governmental agency or department, not including Medicaid. This entitle a Member to benefits if the services are non-covered or do exclusion does not apply to care received in a Veteran’s Hospital or not otherwise meet the conditions and criteria for coverage.
facility unless that care is rendered for a condition that is a result of Routine foot care including any service related to hygiene including the trimming of corns or calluses, flat feet, fallen arches, chronic foot Except as otherwise provided in the evidence of coverage, benefits strain, or partial removal of a nail without the removal of the matrix will not be provided for Habilitative Services. Benefits for physical except when we determine that Medically Necessary treatment was therapy, occupational therapy and speech therapy do not include required because of an underlying health condition such as diabetes, benefits for Habilitative Services.
and that all other conditions for coverage have been met.
Dental care including extractions; treatment of cavities; care of 10.2 Organ and Tissue Transplants.
the gums or bones supporting the teeth; treatment of periodontal Benefits will not be provided for the following: abscess; removal of impacted teeth; orthodontia; false teeth; or any Non-human organs and their implantation.
other dental services or supplies. These services may be covered Any hospital or professional charges related to any accidental injury under a separate rider or endorsement purchased by your Group and or medical condition for the donor of the transplant material.
Any charges related to transportation, lodging, and meals unless Cosmetic surgery (except benefits for Breast Reconstructive Surgery) or other services primarily intended to correct, change or Services for a Member who is an organ donor when the recipient is improve appearances. Cosmetic means a service or supply which is provided with the primary intent of improving appearances and not Any service, supply or device related to a transplant that is not listed for the purpose of restoring bodily function or correcting deformity resulting from disease, trauma, or previous therapeutic intervention as determined by the Plan.
10.3 Inpatient Hospital Services. Benefits will not be provided for the following:
Treatment rendered by a health care provider who is a member of Private room, unless Medically Necessary and authorized or the Member’s family (parents, spouse, brothers, sisters, children).
approved by the Plan. If a private room is not authorized or Any prescription drugs obtained and self-administered by the approved, the difference between the charge for the private room Member for outpatient use unless the prescription drug is specifically and the charge for a semiprivate room will not be covered.
covered under the Certificate or a rider or endorsement purchased Non-medical items and convenience items, such as television and by your Group and attached to this Certificate.
Any procedure or treatment designed to alter an individual’s physical A Hospital admission or any portion of a Hospital admission that had not characteristics to those of the opposite sex.
been authorized or approved by the Plan, whether or not services are Services to reverse voluntary surgically induced infertility such as a Medically Necessary and/or meet all other conditions for coverage.
Private duty nursing unless authorized or approved by the Plan.
All assisted reproductive technologies (except artificial insemination) including in vitro fertilization, gamete intra-fallopian tube transfer, 10.4 Hospice Benefits. The following are not covered:
zygote intra-fallopian transfer cryogenic preservation or storage Services, visits, medical equipment or supplies that are not included of eggs and embryo and related evaluative procedures, drugs, in the Plan-approved plan of treatment.
diagnostic services and medical preparations related to the same Services in the Member’s home if it is outside the Service Area.
unless covered under a rider or endorsement purchased by your Group and attached to this Certificate.
Any service for which a Qualified Hospice Care Program does not Fees or charges relating to fitness programs, weight loss or weight customarily charge the patient or his or her family.
control programs; physical conditioning; pulmonary rehabilitation Chemotherapy or radiation therapy, unless used for symptom control.
programs; exercise programs; physical conditioning; use of passive Reimbursement for volunteer services.
or patient-activated exercise equipment.
G. Domestic or housekeeping services.
H. Meal on Wheels or similar food service arrangements.
Prescription Drug Exclusions
I. Rental or purchase of renal dialysis equipment and supplies.
Benefits will not be provided under this Rider for: 1. Any devices, appliances, supplies, and equipment other than those Outpatient Mental Health and Substance Abuse.
specified in Section B, of this Rider.
2. Routine immunizations and boosters such as immunizations for Psychological testing, unless Medically Necessary, as determined foreign travel, and for work or school related activities.
by the Plan, and appropriate within the scope of covered services.
3. Prescription Drugs intended for cosmetic use.
Services solely on court order or as a condition of parole or probation 4. Prescription Drugs administered by a physician or dispensed in a unless approved or authorized by the Plan’s Medical Director.
C. Mental retardation, after diagnosis.
5. Drugs, drug therapies or devices that are considered experimental or investigational by CareFirst BlueChoice. 6. Drugs or medications lawfully obtained without a prescription such Inpatient Mental Health and Substance.
as those that are available in the identical formulation, dosage, form, or strength of a prescription (“Over-the-Counter” medications).
Admissions as a result of a court order or as a condition of parole or 7. Vitamins, except CareFirst BlueChoice will provide a benefit for probation unless approved or authorized by the Plan’s Medical Director.
b. fluoride and fluoride containing vitamins.
c. single entity vitamins, such as Rocaltrol and DHT.
Emergency Services and Urgent Care. Benefit will not be provided for:
8. Infertility drugs or agents for use in connection with infertility Emergency care if the Member could have foreseen the need for the services or treatments that are excluded from coverage under the care before it became urgent (for example, periodic chemotherapy evidence of coverage to which this rider is attached.
9. Any portion of a Prescription Drug that exceeds: Medical services rendered outside of the Service Area which could have a. a thirty-four (34) day supply for Prescription Drugs; or, been foreseen by the Member prior to departing the Service Area.
b. a ninety (90) day supply for Maintenance Drugs.
Charges for Emergency and Urgent Care services received from a 10. Prescription Drugs that are administered or dispensed by a health care non-Plan Provider after the Member could reasonably be expected facility for a Member who is a patient in the health care facility. This to travel to the nearest Plan Provider.
exclusion does not apply to Prescription Drugs that are dispensed by Charges for services when the claim filing and notice procedures stated a Pharmacy on the health care facility’s premises for a Member who is in this Evidence of Coverage have not been followed by the Member.
not a patient in the health care facility.
Charges for follow-up care received in the Emergency or Urgent 11. Prescription Drugs for weight loss.
Care facility outside of the Service Area unless the Plan determine 12. Biologicals and allergy extracts.
that the member could not reasonably be expected to return to the 13. Blood and blood products. (May be covered under the medical benefits in the evidence of coverage to which this rider is attached.) Except for covered ambulance services, travel, whether or not recommended by a Plan Provider.
Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes only and does not create rights Limitations and Exclusions for Medical Devices
not given through the benefit plan.
Benefits will not be provided for the purchase, rental or repair of the following: A. Convenience item. Any item that increases physical comfort or Medical Limitations and Exclusions – CareFirst BlueCross
convenience without serving a Medically Necessary purpose e.g. BlueShield
elevators, hoyer/stair lifts, shower/bath bench.
Furniture items. Movable articles or accessories which serve as a 10.1 Medical Necessity and Appropriateness.
place upon which to rest (people or things) or in which things are Benefits will not be provided for services, tests, procedures or supplies placed or stored e.g. chair or dresser.
which we determine are not necessary for the prevention, diagnosis or Exercise Equipment. Any device or object that serves as a means for treatment of the Member’s illness, injury or condition. Although a service energetic physical action or exertion in order to train, strengthen or supply is listed as covered, benefits will be provided only if it is medically or condition all or part of the human body e.g. exercycle or other necessary and appropriate in the Member’s particular case. A service or supply is medically necessary and appropriate only if, in our judgment it is: Institutional equipment. Any device or appliance that is appropriate Necessary and appropriate for the symptom, diagnosis, prevention for use in a medical facility and is not appropriate for use in the or treatment of the Member’s illness, injury or condition; Consistent with the symptom, diagnosis, prevention or treatment of Environmental control equipment. Any device such as air the Member’s illness, injury or condition; conditioners, humidifiers, or electric air cleaners. These items are The most appropriate supply, treatment or level of service that not covered even though they may be prescribed, in the individual’s can be provided safely to the Member and, if the Member is an inpatient, cannot be provided safely on an outpatient basis; and Eyeglasses, contact lenses, hearing aids, dental prostheses or d. Not primarily for the convenience of the Member or provider.
Corrective shoes, unless they are an integral part of the lower body Services, supplies, and accommodations will not automatically be considered brace, shoe lifts or special shoe accessories.
Medically Necessary because they were prescribed by an Eligible Provider. We may consult with professional medical consultants, peer review committees, or other appropriate sources for recommendations on whether the services, supplies, or accommodations a Member receives are Medically Necessary.
10.2 Accepted Medical Practice. Benefits will not be provided for any
10.10 Other Exclusions. Benefits will not be provided for the following:
treatment, procedure, facility, equipment, drug, drug usage, device or supply Services or supplies received before the effective date of your which, in our judgment, is experimental, investigational or not in accordance with accepted medical or psychiatric practices and standards in effect at Treatment of sexual dysfunctions or inadequacies except surgical the time of treatment. A service or supply is deemed to be experimental or implants for impotence (medical therapy and psychiatric treatment A preponderance of scientific data, such as controlled studies in peer- Any procedure or treatment designed to alter an individual’s reviewed journals or literature has not demonstrated that its use physical characteristics to those of the opposite sex.
results in an improved net health outcome for a specific diagnosis; Weight reduction or obesity treatment, except the surgical It is not in accordance with generally accepted standards of medical Speech therapy, occupational therapy or physical therapy, unless we It does not have federal or other required governmental agency determine that your condition is subject to improvement. Coverage approval at the time it is received.
does not include nonmedical ancillary services such as vocational This exclusion will not be used, however, to deny Patient Cost when rehabilitation, employment counseling, or educational therapy.
the services for Clinical Trials meet all the requirements under the Fees and charges relating to fitness programs, weight loss or weight section entitled “Clinical Trial”.
control programs, physical, pulmonary conditioning programs or other programs involving such aspects as exercise, physical conditioning, 10.3 Free Care. Payment will not be made for services which, if the Member
use of passive or patient-activated exercise equipment or facilities were not covered under the Group Contract, would have been provided and self-care or self-help training or education. Cardiac rehabilitation without charge, including any charge or any portion of a charge which, by programs are covered as described in your Agreement.
law, the provider is not permitted to bill or collect from the patient directly.
Services or supplies for the medical or surgical treatment of errors of refraction, such as myopia or hyperopia, including but not 10.4 Routine Care of Feet. Benefits will not be provided for any services related
limited to radial keratotomy or any like or similar procedures or any to hygiene and preventative maintenance such as trimming of corns, calluses, flat feet, fallen arches, chronic foot strain or partial removal of a nail without Services to the extent they are covered by any governmental unit, the removal of its matrix, in the absence of an underlying health condition.
except in Veteran’s Administration or armed forces facilities for services received, such as for non-service connected disabilities, 10.5 Dental Care. Except as provided in the evidence of coverage,
for which the recipient is liable. Services or supplies for injuries or benefits will not be provided for any other type of dental care including diseases related to a covered person’s job to the extent the covered extractions, treatment of cavities, care of the gums or bones supporting person is required to be covered by a workers’ compensation law. the teeth, treatment of periodontal abscess, removal of impacted teeth, Services or supplies resulting from accidental bodily injuries orthodontia, false teeth or any other dental services or supplies, unless arising out of a motor vehicle accident to the extent the services provided in a separate Rider or Endorsement to this Agreement.
are payable under a medical expense payment provision of an automobile insurance policy, excluding no fault insurance.
10.6 Oral Surgery. Except as otherwise provided in the evidence of coverage,
Services that are beyond the scope of the license of the provider benefits will not be provided for procedures involving the teeth or areas surrounding the teeth including the shortening of the mandible or maxillae Except for covered ambulance services, travel, whether or not for cosmetic purposes or for correction of malocclusion are excluded.
recommended by an Eligible Provider.
Services or supplies for conditions that State or local laws, 10.7 Cosmetic Services. Benefits will not be provided for cosmetic surgery
regulation, ordinances, or similar provisions require to be provided (except benefits for Reconstructive Breast Surgery and the treatment of morbid obesity) or other services primarily intended to correct, change or Services or supplies received from a dental or medical department improve appearances. Cosmetic means a service or supply which is provided maintained by or on behalf of an employer, mutual association, with the primary intent of improving appearances and not for the purpose labor union, trust, or similar persons or groups.
of restoring bodily function or correcting deformity resulting from disease, trauma, or previous therapeutic intervention as determined by the Plan.
Assistive reproductive procedures, except when provided in a separate rider or endorsement to your Agreement.
10.8 Prescription Drugs. Except as provided in a separate rider or endorsement
Services solely on court order or as a condition of parole or to this Agreement, benefits will not be provided for prescription drugs, probation unless approved by the Plan.
unless administered to the Member in the course of covered outpatient or Any illness or injury caused by war, declared or undeclared, inpatient treatment. Take-home prescriptions or medications, including self- administered injections which can be administered by the patient or by an Any service, supply or procedure which is not specifically listed in average individual who does not have medical training, or medications which your Agreement as a covered benefit.
do not medically require administration by or under the direction of a physician Except as otherwise provided in the evidence of coverage, benefits are not covered, except as may be provided in a separate rider or endorsement will not be provided for Habilitative Services. Benefits for physical to this Agreement, even though they may be dispensed or administered in a therapy, occupational therapy and speech therapy do not include physician or provider office or facility.
benefits for Habilitative Services.
10.9 Organ Transplants. Organ transplant procedures, including complications
resulting from any such procedure, services or supplies related to any such
procedure such as, but not limited to, high dose chemotherapy, radiation
therapy or any other form of therapy, or immunosuppressive drugs are not
covered, except as provided in your Agreement.
Limitations and Exclusions for Medical Devices
Prescription Drug Exclusions
a. Benefits will not be provided for purchase, rental or repair of: Benefits will not be provided under this rider for: Medical equipment/supplies of an expendable nature, except as 1. Any devices, appliances, supplies, and equipment except as specifically listed as a Covered Medical Supply in paragraph b., above. otherwise provided in Section B, above.
Non-covered supplies include incontinence pads and ace bandages.
2. Routine immunizations and boosters such as immunizations for Equipment that can be used for non-medical purposes, such as foreign travel, and for work or school related activities.
air conditioners, humidifiers, electric air cleaners. These items 3. Prescription Drugs for cosmetic use.
are not covered even though they may be prescribed, in the 4. Prescription Drugs administered by a physician or dispensed in a individual’s case, for a medical reason.
Equipment that basically serves comfort or convenience 5. Drugs, drug therapies or devices that are considered experimental functions or is primarily for the convenience of a person caring for a Member, i.e., exercycle or other physical fitness equipment, 6. Drugs or medications lawfully obtained without a prescription elevators, hoyer lifts, shower/bath bench.
such as those that are available in the identical formulation, Eyeglasses or contact lenses (except as stated above), hearing dosage, form, or strength of a prescription (“Over-the-Counter” aids or dental prostheses or appliances.
Corrective shoes (unless required to be attached to a leg brace), 7. Vitamins, except CareFirst will provide a benefit for Prescription Drug: shoe lifts or special shoe accessories.
Benefits will be limited to the lower of purchase or rental, taking b. fluoride and fluoride containing vitamins.
into account the length of time you required or are reasonably c. single entity vitamins, such as Rocaltrol and DHT.
expected to require the equipment, the durability of the equipment, 8. Infertility drugs and agents for use in connection with infertility services or treatments that are excluded from coverage under the The purchase price or rental cost must be the least expensive of evidence of coverage to which this rider is attached.
its type adequate to meet the medical needs of the Member. If 9. Any portion of a Prescription Drug that exceeds the Member selects a deluxe version of the appliance, device or (34)-day supply for Prescription Drugs; or, equipment not determined by us to be medically necessary, we will (90)-day supply for Maintenance Drugs.
pay an amount which does not exceed our payment for the basic 10. Prescription Drugs that are administered or dispensed by a health device (minus the Member copayment) and the Member will be fully care facility for a Member who is a patient in the health care responsible for paying the remaining balance.
facility. This exclusion does not apply to Prescription Drugs that are Benefits for the repair, maintenance or replacement of Covered dispensed by a Pharmacy on the health care facility’s premises for Durable Medical Equipment are limited as follows: a Member who is not a patient in the health care facility.
Coverage of maintenance costs is limited to routine servicing such 11. Prescription Drugs for weight loss.
as testing, cleaning, regulating and checking of equipment.
12. Biologicals and allergy extracts.
Coverage of repairs costs is limited to adjustment required by 13. Blood and blood products. (May be covered under the medical normal wear or by a change in the Member’s condition and repairs benefits in the evidence of coverage to which this rider is attached.) necessary to make the equipment/appliance serviceable. Repair will not be authorized if the repair costs exceed the market value Not all services and procedures are covered by your benefits contract. This of the appliance, prosthetic or equipment.
list is a summary and is not intended to itemize every procedure not covered Replacement coverage is limited to once every two years due to by CareFirst BlueCross BlueShield. This plan summary is for comparison irreparable damage and/or normal wear or a significant change purposes only and does not create rights not given through the benefit plan.
in medical condition. Replacement costs necessitated as a result of malicious damage, culpable neglect, or wrongful disposition of the equipment or device on the part of the Member or of a family Member are NOT covered.

Source: http://www.hil.us/wp-content/uploads/2012/08/CareFirst-Prescription-Drug-Summary.pdf