Prescription Rider Rx D - 10/15/30
The following rider is an addendum to the "Subscriber Contract" which provides for the provision of all basic health services.
The "Benefits" section of the Subscriber Contract is amended as follows:
Outpatient Prescription Drugs or Medicines.
- Outpatient FDA approved prescription drugs or medicines are covered when medically necessary and prescribed by a licensed Participating Physician. Each prescription is limited to a maximum 34-day supply, with up to four refills when authorized by a licensed Participating Physician.
- Prescriptions must be filled at a Participating Pharmacy. If a Participating Pharmacy is not available within a 30 mile radius, (i.e. you are visiting out of the service area), Atlantis Health Plan ("the Plan") will reimburse you directly, subject to utilization review, the cost in full, less co-payment as otherwise specified in this Rider.
Prescription drug coverage also includes:
- Medically necessary enteral formulas for home use when prescribed by a licensed provider. The formula must have been proven effective as a disease-specific treatment regime for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic disability, mental retardation or death.
- Modified solid food products that are low protein, when medically necessary for certain inherited diseases of amino acids and organic metabolism.
- Hypodermic needles and syringes used to administer medications that are covered by Atlantis, when prescribed by a licensed practitioner and purchased through a Plan Pharmacy.
- Certain non-FDA approved prescribed drugs recognized for the treatment of specific
types of cancer by one of the following:
- the American Medical Association Drug Evaluations;
- the American Hospital Formulary Service Drug Information; or
- the United States Pharmacopeia Drug Information; or recommended by review article or editorial comment in a major peer reviewed professional journal.
- Pre-natal Vitamins when prescribed by a Participating Physician.
- Allergy Serums.
Mail Order/ Maintenance
- You are encouraged to utilize our Mail Order/ Maintenance program if you are required to use a maintenance drug on the Plan's approved list.
- Maintenance drugs are covered for a 90-day supply upon a written prescription by a Participating Physician.
- The list of approved Maintenance Drugs is subject to change. If you currently use a maintenance drug that is not on the list, please contact our Member Services Department.
- You are responsible for a $10 co-payment for each generic prescription filled at a Participating Pharmacy.
- You are responsible for a $15 co-payment for each brand formulary prescription filled at a Participating Pharmacy.
- You are responsible for a $30 co-payment for each brand non-formulary prescription filled at a Participating Pharmacy.
- The co-payment for a 90 day supply of a maintenance drug through our Mail Order program is $15 for generic drug; $22.50 for brand formulary drug and $45 for non-formulary drug
Limitations and Exclusions
Except to the extent that such benefits are either medically necessary or are required to be provided by applicable Law, prescription drug benefits do not include:
All of the terms, conditions and limitations of your Atlantis Health Plan Health Plan Subscriber Contract to which this rider is attached also apply to this Rider, except where specifically changed by this Rider.
- Any drug which does not require a prescription, such as over-the-counter or non-legend drugs, even if a prescription is written.
- Any durable medical equipment appliance or device.
- All drugs and medications used for treating infertility, to include Clomiphene tablets and injectable Metrodin and Pergonal, unless required by applicable Law.
- Antibacterial soaps/detergents, shampoos, toothpaste/gels and mouthwashes/rinses.
- Prescription drugs dispensed to a Member while he is a patient in a hospital, nursing home, or other institution.
- Prescription drugs used in connection with drug addiction, unless medically necessary and pre-authorized by Atlantis.
- Amphetamines, appetite suppressants, and hair growth stimulants unless medically necessary and pre-authorized by Atlantis.
- Medications for cosmetic purposes only.
- Prescription drugs dispensed by a physician/provider office.
- Experimental and Investigational Drugs which are defined as drugs which have not been approved by the FDA and or NIH or have not been shown to be safe and effective through clinical trials or are not generally accepted as safe and effective by a majority of clinical providers with significant experience in the usage of the drugs.
- Replacements of drugs resulting from loss, theft or breakage.
- The maximum coverage for any authorized modified solid food products for any calendar year or for any continuous period of 12 months shall not exceed $2,500.
- Some drugs require Pre-authorization. Participating Physician's are responsible for obtaining the necessary authorization prior to prescribing the drug.
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