Microsoft word - modified rx 4 drug benefit.doc
Modified IBEW Local 18
RX 4 Drug Benefits
At Anthem Blue Cross, we know that prescription drugs are
Finding a Participating Pharmacy
the fastest–rising item of your total health care benefits cost.
Because our huge pharmacy network includes major
Reasons for the spiraling costs of prescription drugs are
drugstore chains plus a wide variety of independent
varied: a general increase of prescription medication use,
pharmacies, it is easy for you to find a participating pharmacy. You can also find a participating pharmacy by
an aging population, research and development of new
going to our Web site at www.anthem.com/ca.
medications and the expense of direct to consumer advertising. With prescription drug costs increasing at twice
An Extensive Network
Besides saving you money, our extensive network of pharmacies
the rate of medical care, we developed ways to contain costs
so your copays remain affordable, while maintaining your
In California there are over 5,100 retail pharmacies.
access to safe, effective prescription drugs. Our Prescription
This accounts for nearly 95% of retail pharmacies in the state,
Drug Program provides you with choice, flexibility,
affordability and access to an extensive network of retail
Nationwide there are more than 61,000 chain and independent
Getting a Prescription Filled at a Participating Pharmacy
Using a Participating Pharmacy
To get a prescription fil ed, you need only take your prescription to
You can substantial y control the cost of your prescription drugs by
a participating pharmacy and present your member ID card. The
using our extensive network of participating pharmacies.
amount you pay for a covered prescription – your copay – wil be
Participating pharmacies have agreed to charge a discounted price
determined by whether the drug is brand-name or generic
or “negotiated rate” and pass along this savings to you.
medication and whether it is a preferred or non-preferred medication.
Using a Non-Participating Pharmacy
A generic drug contains the same effective ingredients, meets the
If you choose to fil your prescription at a non-participating
same standards of purity as its brand-name counterpart and
pharmacy, your costs wil increase. You wil likely need to pay for
typical y costs less. In many situations, you have a choice of fil ing
the entire amount of the prescription and then submit a prescription
your prescription with a generic medication or a brand-name
drug claim form for reimbursement. The pharmacist must sign and
complete the appropriate section of the claim form to ensure proper processing of the claim for reimbursement.
Our Preferred Drug Program (PDP) encourages the usage of certain, lower-cost, but equal y effective, prescription medications
The fol owing chart il ustrates potential increased out-of-pocket
(preferred drugs) in place of higher-cost medications (non-preferred
expenses for going to a non-participating pharmacy:
drugs). The non-preferred list contains medications that require
your physician’s approval before they can be substituted for a
preferred medication. By al owing this substitution, the PDP helps
you better manage the increasing cost of prescription drugs while
stil maintaining your access to safe and effective medications.
The fol owing chart il ustrates the relation between drug type and
your copay amount at a participating pharmacy:
Expense varies based
on the cost of the
You may obtain a prescription drug claim form by cal ing Pharmacy Customer Service at the tol -free number printed on your member ID card or by going to our Web site at www.anthem.com/ca.
Submitting a Claim Form
are the proper FDA recommendations for
Check to see that al sections of the claim form are completed and
prescription medication dosage coupled with our determination of
specific quantity supply limits to prescription medications. Although
our standard pharmacy plans offer a 30-day supply for medications
at a retail pharmacy, the supply limit can vary based on the
medication, dosage and usage prescribed by your physician. For
example, the supply limit for antibiotics used to treat an infection
Mail Service Prescription Drug Program
(e.g., 14 pil s to be taken twice a day for one week) is different than
If you take a prescription drug on a regular basis, you may want to
blood pressure medication taken on a routine basis (e.g., 120 pil s
take advantage of our mail service program. Ordering your
to be taken twice a day for 60 days). By adhering to specified
medications by mail is convenient, saves time and depending on
supply limits, members are assured of receiving the appropriate
your plan design, may even save you money. Besides enjoying the
convenience of home delivery, you wil also receive a greater
Programs for Member’s Special Health Needs
supply of medications. To fil a prescription through the mail, simply
We recognize that some of our members have unique health care
complete the Mail Service Prescription form. You may obtain the
needs requiring special attention. That’s why we developed
form by cal ing Customer Service, at the tol -free number listed on
programs exclusively for them. Our additional medical management
your ID card or by going to our Web site at www.anthem.com/ca.
programs work in synergy with our pharmacy drug program to help
Once you complete the form, simply mail it with your copay and
members better manage their health care on an ongoing basis.
prescription in the envelope attached to the Mail Service brochure.
can receive free glucometers
so that they can
Please note that not al medications are available through the Mail
effectively and conveniently monitor their glucose levels.
can better monitor their chronic diseases and multiple
medications through our seniors-at-risk program.
Out-Of-State Prescription Benefits
reduces the possibility of toxic drug interactions,
Our national network of participating pharmacies is available to
distribution of medications that may adversely affect the senior’s
members when outside California. To find a participating pharmacy,
a member can check our Web site or cal the tol -free number printed on the ID card. When using a non-participating pharmacy
and their families can take advantage of our
outside of California, the member wil fol ow the same procedures
program to better control the frequency and severity of the disease.
for using a non-participating pharmacy in California as outlined
Members who take multiple prescription medications
advantage of our pharmacy utilization management programs that
Additional Features That are Part of your Plan
encourage the safe, effective distribution of prescription medications. We have a program that protects the welfare of
as the term implies, is similar to prior
members with multiple prescription medications by careful y
authorization for medical services. Prior authorization applies to a
monitoring their prescription therapy to help reduce the danger of
select pool of medications that are often a second line of therapy.
To require prior authorization, a drug must meet specific criteria. This criteria is based, among other things, on FDA-approved drug
For additional information regarding your prescription drug benefits,
indications, targeted populations and the current availability of
please cal Pharmacy Customer Service at the
effective drug therapies. Prior authorization drugs are not covered
tol -free number printed on your member ID card.
unless you receive an approval from Anthem Blue Cross.
Please refer to your Combined Evidence of Coverage and
We distribute instructions on how to obtain prior authorization to
Disclosure Form which explains your plan’s Exclusions and
physicians and pharmacies so that you may obtain prior
Limitations as wel as the ful range of your covered services in
authorization for required medications. You may cal Pharmacy
Customer Service, at the tol -free number printed on your member
ID card, to receive a prior authorization form and/or list of
medications requiring prior authorization.
Covered Services (outpatient prescriptions only)
Per Member Copay for Each Prescription or Refill
Participating Retail Pharmacy
Member pays the above copay plus:
30-day supply; 60-day supply for federal y classified
(participating and non-participating)
Schedule II attention deficit disorder drugs that require a
triplicate prescription form, but require a double copay;
6 tablets or units/30-day period for impotence and/or
sexual dysfunction drugs (available only at retail pharmacies)
1Supply limits for certain drugs may be different. Please refer to the Evidence of Coverage and Disclosure form (EOC) for complete information.
The Prescription Drug Benefit covers the following:
Outpatient prescription drugs and medications. Formulas prescribed by a physician for the treatment of phenylketonuria.
These formulas are subject to the copay for brand name drugs.
Insulin. Syringes when dispensed for use with insulin and other self-injectable drugs or medications. Prescription oral contraceptives; contraceptive diaphragms. Contraceptive diaphragms are limited to one per year and are subject to the
Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or family member. Drugs that
have Food and Drug Administration (FDA) labeling for self-administration
Al compound prescription drugs that contain at least one covered prescription ingredient. Diabetic supplies (i.e., test strips and lancets). Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes.
Prescription drug copays are separate from the medical copays of the medical plan and are not applied toward the Annual
Prescription Drug Exclusions & Limitations
Immunizing agents, biological sera, blood, blood products or blood plasma
Drugs which have not been approved for general use by the State of California Department of
Hypodermic syringes &/or needles, except when dispensed for use with insulin & other self-
Health or the Food and Drug Administration
Drugs & medications used to induce spontaneous & non-spontaneous abortions
Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles)
Drugs & medications dispensed or administered in an outpatient setting, including outpatient
Drugs used primarily to treat infertility (including, but not limited to, Clomid, Pergonal and Metrodin)
hospital facilities and physicians’ offices
Anorexiants and drugs used for weight loss, except when used to treat morbid obesity (e.g., diet
Professional charges in connection with administering, injecting or dispensing drugs
Drugs & medications that may be obtained without a physician’s written prescription, except insulin
Al ergy desensitization products or al ergy serum
Drugs & medications dispensed by or while confined in a hospital, skil ed nursing facility, rest home,
Infusion drugs, except drugs that are self-administered subcutaneously
sanatorium, convalescent hospital or similar facility
Select classes of drugs where non-preferred medications, which have therapeutic alternatives, have
Durable medical equipment, devices, appliances & supplies, even if prescribed by a physician,
shown no benefit regarding efficacy or side effect over preferred drugs; however, this wil not apply
except contraceptive diaphragms, as specified as covered in the EOC
if the prescriber denotes “dispense as written” or “do not substitute”
Services or supplies for which the member is not charged
Herbal, nutritional and dietary supplements except for formulas for the treatment of phenylketonuria.
Prescription drugs with a non-prescription (over-the-counter) chemical and dose equivalent except
Drugs labeled “Caution, Limited by Federal Law to Investigational Use,” or experimental drugs.
Third Party Liability
Drugs or medications prescribed for experimental indications
Anthem Blue Cross is entitled to reimbursement of benefits paid if the member recovers damages
Any expense for a drug or medication incurred in excess of (a) the Drug Limited Fee Schedule for
drugs dispensed by non-participating pharmacies; or (b) the prescription drug negotiated rate for drugs dispensed by participating pharmacies or through the mail service program
Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of
the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name
and symbol are registered marks of the Blue Cross Association.
The Cognitive Symmetry Engine: An Active Approach to Knowledge Abstract • Interaction knowledge; i.e., knowledge of the relationof self to the external world and the possible interac- Knowledge acquisition and representation is an integral part of an active cognitive system, and such systems arecontinuously updating their knowledge of their own embod- iment, the external world and the r
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