PRESCRIPTION DRUG RIDER
This Prescription Drug Rider (“Rider”) is made a part of Coventry Health and Life Insurance Company’s Certificate of Coverage (“COC”). The benefits provided by this Rider become effective on the date Coverage under the COC is effective. PRESCRIPTION DRUG BENEFITS Subject to the terms, conditions and scope of coverage, including all Exclusions, Limitations and defined terms of the COC unless otherwise provided in this Rider, Member Responsibility and Ancillary Charges, outpatient Prescription Drugs will be Covered as listed below, when:
· the Member is eligible to receive Covered Services;
· written by a Prescribing Provider; and
· filled at a pharmacy. Generically equivalent pharmaceuticals will be dispensed whenever there is an FDA approved Formulary Generic drug. If you choose to receive a brand name Prescription Drug when a Formulary Generic Drug is available, You will be responsible for the Ancillary Charge and the Member Responsibility. The Ancillary Charge will be due regardless of whether or not the Prescribing Provider indicates that the pharmacy is to "Dispense as Written." Your total Member Responsibility shall not exceed the total allowable cost of the Prescription Drug.
Member Responsibility Benefit1,2 Non-Participating ail Order Participating Pharmacy Pharmacy Formulary Tier 1A Prescription Formulary Tier 1B Prescription Formulary Tier 2 Prescription Non-Formulary Prescription Formulary Tier 4 Specialty Drugs
Copayment, which ever is greater Copayment, which ever is greater up to $200 maximum per up to $400 maximum per individual individual prescription
$3,500 Out of Pocket¹ Maximum $7,000 Out of Pocket¹ Maximum (per Benefit Year)
1. Copayments and Ancillary Charges do not apply to the Coinsurance Maximum listed on the Schedule of Benefits. 2. To find Your Prescription Drug, its applicable Tier and any Pre-Certification requirements, visit Our serachable Formulary on
Our websiten the Participating Provider’s office, or by contacting the Customer Service Department.
The following also apply: ·
Member Responsibility is due each time a prescription is filled or refilled, up to a thirty-one (31) day supply for Retail and Specialty Pharmacy, and up to a ninety-three (93) day supply for Mail Order Pharmacy.
Select over-the-counter medications as determined by the Plan in an equivalent prescription dosage strength will be covered under this Rider for the appropriate Member Responsibility. Coverage of the selected over-the-counter medications requires a physician prescription.
Only one drug and “Rx Unit” will be dispensed per prescription. The Rx Unit quantity is determined by FDA labeling, the dosage required or the Plan Formulary guidelines. Please note: Member Responsibility is required for each Rx Unit, container, or prepackaged item.
If a Prescription Drug covered is prescribed in a single dosage amount for which the particular prescription drug is not manufactured in such single dosage amount and requires dispensing the particular prescription drug in a combination of different manufactured dosage amounts, the Member Responsibility will be the same as if the Prescription Drug was manufactured in such single dose.
Members presently taking a prescription drug shall be notified either electronically, or in writing (upon request of the enrollee), at least thirty (30) days prior to any deletions to the Formulary. Notifications will not be provided for Generic substitutions.
Value Formulary drugs are offered at no Member Responsibility on a temporary basis to Members that are on or have recently received certain drugs(s) and/or receive a new prescription for certain drug(s), as designated by the Plan to promote effective and efficient use of the Plan drug benefits. These drugs are listed in an addendum to the Formulary, which may be found on the our website at The formulary addendum shall also identify the Plan Criteria applicable to the Value Formulary Drugs. Thisformulary addendum may change from time to time without prior notice. Members that appear to meet the Plan criteria for Value Formulary Drugs (as such information is available in Plan’s claims records) will be notified if they qualify for a Value Formulary drug, when such drugs are temporarily added. Please note, just because a Member fills a prescription for a Value Formulary drug does not qualify him/her to receive such drug at no Member Responsibility. Rather, only Members that meet Plan criteria will receive the selected drug at no Member Responsibility. If a Member does not satisfy the Value Formulary drug Plan criteria, the drug shall be subject to its applicable Member Responsibility. DEFINITIONS
Any capitalized terms used in this Rider and not otherwise defined herein shall have the meaning set forth in the COC. The following definitions apply to this Rider: Ancillary Charge. A charge in addition to the Member Responsibility You are required to pay for a Prescription Drug which, through Your request or that of the Prescribing Provider, has been dispensed by the brand name, even though a Formulary Generic is available. The Ancillary Charge, if any, shall be the difference between the Plan’s contracted price for the Non-Formulary or Formulary brand name drug and the contracted price of the generic drug. The Ancillary charge will be in addition to the appropriate Member Responsibility. You are responsible at the time of service for payment of the Ancillary Charge directly to the Pharmacy. The Ancillary Charge is not a Covered charge and does not apply to an Deductible, Coinsurance, or Out-of-Pocket Maximum. Copayment. The amount You will be charged by the Pharmacy to dispense or refill any Prescription. You are responsible at the time of service for payment of the Copayment directly to the Pharmacy.
Formulary. A list of specific generic and brand name Prescription and Specialty Drugs Authorized by the Plan, and subject to periodic review and modification at least annually by the Plan’s Pharmacy and Therapeutics Committee. The Formulary is available for review in the searchable Formulary on Our website, in the Participating Provider’s office, or by contacting the Customer Service Department. Please note: Inclusion of a drug within the Formulary does not guarantee that Your health care provider will prescribe that drug for a particular medical condition or illness. Formulary Prescription Drug. A Prescription and Specialty Drug that appears on the Plan’s Formulary. Generic Prescription Drug. A Prescription Drug as being prescribed by its generic and chemical name heading according to the principal ingredient(s) and approved by the Food and Drug Administration. Mail Order Pharmacy. A Pharmacy that dispenses Maintenance Medications pursuant to a 93 day/cycle supply. Prescription Drugs determined by the Plan to be Maintenance Medications on the Formulary and prescribed by a Prescribing Provider can be filled by mail order. Maintenance Medication(s). A medication that is listed and identified on the Formulary as a maintenance prescription. Member Responsibility. The dollar amount detailed under Prescription Drug Benefits which must be paid by You to a Pharmacy providing a Prescription Drug covered by this Rider. Non-Formulary Prescription Drug. A Prescription Drug that is not on the Plan’s list of Formulary Prescription Drugs. Non-Participating Pharmacy. Any pharmacy that is not a Participating Pharmacy as defined herein. A Prescription Order or Refill may be obtained through a Non-Participating Pharmacy, however, You may be required to pay for the cost of the Prescription Drug(s) and file a claim for reimbursement. Participating Pharmacy. A pharmacy licensed in the State in which it is located that has entered into a written contract with the Plan to provide services to the Plan’s Members, or on whose behalf a written contract has been made with the Plan which is in effect at the time services are provided. Pre-Certification. Some drugs require Pre-Certification in order for them to be Covered Services. Drugs requiring Pre-Certification are identified within the Formulary with “PA” next to the name of the drug. Prescribing Provider. Any person holding the degree of Doctor of Medicine, Doctor of Osteopathy, Doctor of Dental Medicine, or Doctor of Dental Surgery or any other provider who is duly licensed in the United States to prescribe medications in the ordinary course of his or her professional practice. Prescription Drug(s). Any medication or drug which:
· is provided for outpatient administration;
· has been approved by the Food and Drug Administration; and
· under federal or state law, is dispensed pursuant to a prescription order (legend drug). CHL-KSMO-RID-213-03.10R
This definition of Prescription Drug may include some over-the-counter medications or disposable medical supplies (e.g., insulin and diabetic supplies), psychotherapeutic drugs used for treatment of mental illness, other than when administered in a hospital or provider’s office, and a compound substance when it meets the Plan’s criteria and the product is not available commercially. Prescription Order or Refill. The authorization for a legend Prescription Drug issued by a Prescribing Provider who is duly licensed to make such an authorization in the ordinary course of his or her professional practice. Retail Pharmacy. Prescription Drugs prescribed by a Prescribing Provider and obtained through a Pharmacy. Specialty Drug. Those drugs listed on the Specialty Drug Formulary and identified with an “SP”. Specialty Drugs are typically used to treat rare or complex disease. These drugs frequently require special handling, close clinical monitoring and management and Pre-Certification prior to being dispensed. Specialty Pharmacy. A pharmacy that is designated as a Specialty Pharmacy by the Plan for Specialty Drug Prescription Orders or Refills. Step Therapy. A process where the Plan or its designee determines that a Prescription Order or Refill based upon information provided by the Prescribing Provider, the Prescription Order or Refill satisfies the Pre-Certification requirements for Coverage. Certification must be obtained prior to dispensing. LIMITATIONS 1. Authorized refills will not be provided after the lesser of:
i. twelve (12) months from the original date on the prescription order; or ii. the period of time limited by state or federal law.
2. Contraceptive diaphragms prescribed by a Prescribing Provider are limited to two (2) per year. 3. Coverage of injectable drugs is limited to insulin, glucagon, bee sting kits, Imitrex and
injectable contraceptives that are commonly and customarily administered by the Member.
4. Selected products, as defined by the plan, with narrow therapeutic index, potential for misuse
and/or abuse, high cost, or a narrow or limited range of Food and Drug Administration approved indications may require Pre-Certification.
5. The Pharmacy shall not dispense a Prescription Drug order which, in the Pharmacist’s
professional judgment, should not be filled.
6. To promote appropriate utilization, or following manufacturer’s recommendations, certain plan
approved medications may have a quantity limit on the amount of medication dispensed and pre-certification must be obtained prior to dispensing.
7. We reserve the right to include only one dosage or form of a drug on our Formulary when the
same drug (i.e., a drug with the same active ingredient) is available in different dosages or forms (i.e., dissolvable tablets, capsules, etc) from the same or different manufacturers. The
product, in the dosage or form, that is listed on the Formulary will be Covered at the applicable Member Responsibility. The drug, product or products, in different forms or dosages or from the same or different manufacturers, not listed on the Formulary will be excluded from coverage.
8. Coverage of Prescription Drugs, therapeutic devices or supplies requiring a Prescription Order
and prescribed by a Prescribing Provider is limited to Plan approved drugs, devices, supplies, or spacers for metered dose inhalers.
9. Coverage through the Mail Order Pharmacy is not available on drugs that cannot be shipped by
mail due to state or federal laws or regulations, or when the Plan considers shipment through the mail to be unsafe. Examples of these types of drugs include, but are not limited to, narcotics, amphetamines, DEA controlled substances or anticoagulants.
10. When You use a Non-Participating Prescribing Provider, it is Your responsibility to contact the
Plan before a Prescription Order or Refill is filled to obtain any required Pre-Certification. If the Plan is not contacted for Pre-Certification, You will be required to pay one hundred percent (100%) of the cost for a Prescription Drug.
EXCLUSIONS The following are Excluded from Coverage under this Rider: 1. Prescription Drugs related to the treatment of a Non-Covered Service (i.e. dental services). 2. Prescription Drugs that are not Medically Necessary. The Plan reserves the right to require
medical Pre-Certification for selected drugs before providing Coverage.
3. Prescription Drugs that are Experimental or Investigational, including those labeled “Caution-
limited by Federal Law to Investigational Use,” FDA approved drugs used for investigational indications or at investigational doses and drugs found by the FDA to be ineffective or given as a part of a study.
4. Products not approved by the FDA, Prescription Drugs with no FDA approved indications, and
DESI Drugs. This exclusion shall not apply to a drug, medicine or medication that is recognized for the treatment of cancer in one of the standard reference compendia or in substantially accepted peer-review medical literature.
5. Any Prescription Drug which is to be administered, in whole or in part, while You are in a
hospital, medical office or other health care facility.
6. Compounded prescriptions are excluded unless all of the following apply:
a. there is no suitable commercially-available alternative available; b. the main active ingredient is a Covered Prescription Drug; c. the purpose is solely to prepare a dose form that is Medically Necessary and is documented
d. the claim is submitted electronically by the Pharmacy.
7. Vitamins and minerals (both over-the-counter and legend), except as specified on the
8. Injectable medications and Specialty Drugs, except those designated by the Plan. 9. Drugs that do not require a prescription by federal or state law, that is, over-the-counter drugs
or over-the-counter products, unless specifically designated for Coverage by the Plan or the Formulary list and obtained from the Pharmacy with a Prescription Order or Refill. Also excluded are Prescription medications that are not for treatment of illness, injury, or have an over-the-counter equivalent, unless otherwise specified on the Formulary.
10. Devices or supplies of any type, even though requiring a Prescription Order, such as but not
limited to, therapeutic devices, support garments, corrective appliances, non-disposable hypodermic needles, syringes or other devices, regardless of their intended use, unless otherwise specified as a Covered benefit in this Rider.
11. Contraceptive implant systems, prescription or nonprescription contraceptive devices (e.g.,
condoms, spermicidal agents, and Norplant).
12. Extemporaneous dosage forms of natural estrogen or progesterone; or any natural hormone
replacement product, including but not limited to oral capsules, suppositories, creams and troches.
13. Anti-smoking medication or smoking cessation devices. 14. Prescription Drugs used to treat chemical dependency and/or substance abuse. 15. Drugs used primarily for hair restoration. 16. Pharmacological therapy for weight reduction, dietary supplements, appetite suppressants, and
other drugs used to treat obesity, morbid obesity or assist in weight reduction.
17. Drugs, oral or injectable, used for the primary purpose of, or in connection with, treating
infertility, fertilization, and/or artificial insemination.
18. Medications used for cosmetic purposes or to enhance work or athletic performance (i.e.
Nuvigil or Provigil for shift work, anabolic steroids and minoxidil lotion, retin A (tretinoin) for aging skin). Also excluded are drugs, oral or injectable, used to slow or reverse normal aging processes (i.e. growth hormone, testosterone, etc.).
19. Prescription Drugs dispensed in unit doses, when bulk packaging is available, or repackaged
20. Replacement for lost, destroyed or stolen prescriptions. 21. Duplicate drug therapy (i.e. two antihistamine drugs). 22. Oral dental preparations and fluoride rinses, except pediatric fluoride tablets or drops as
23. Prescriptions that You are entitled to receive without charge under any Workers’
Compensation law, occupational statute, or any law, or regulation of similar purpose.
1. The Plan and its designees shall have the right to release any and all records concerning
health care services that are necessary to implement and administer the terms of this Rider or for appropriate medical/pharmaceutical review or quality assessment.
2. The Plan shall not be liable for any claim, injury, demand or judgment based on tort or other
grounds (including warranty of drugs) arising out of or in connection with the sale, compounding, dispensing, manufacturing, or use of any Prescription Drug whether or not Covered under this Rider.
1. Your Coverage under this Rider will end when Coverage under the COC ends. 2. Nothing herein shall be held to vary, alter, waive, or extend any of the definitions, terms,
conditions, provisions, agreements or limitations of the COC, other than as stated above.
3. Discounts and Rebates. Member understands and agrees that Health Plan may receive a
retrospective discount or rebate from a Network Provider or vendor related to the aggregate volume of services, supplies, equipment or pharmaceuticals purchased by persons enrolled in health care plans offered or administered by Health Plan and its affiliates. Member shall not share in such retrospective volume-based discounts or rebates. However, such rebates will be considered, in the aggregate, in Health Plan's prospective premium calculations.
Michael G. Murphy Authorized Signatory
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