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(Available to Washington State Residents Only)
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SUMMARY OF BENEFITS
INDIVIDUAL PLANS
PRESCRIPTION DRUGS
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Getting Your Prescription Filled: Prescription drugs and other covered items must be furnished by a participating pharmacy or a mail order supplier approved by the Company. There are more than 750 approved pharmacies in our network.
- Present your identification card at a participating pharmacy and pay your applicable coinsurance amount.
- Prescription drugs furnished by a participating pharmacy will be limited to a 34-day supply, except as otherwise specified.
- Certain maintenance drugs for chronic conditions, which are listed in the Company's maintenance medication list will be limited to 100 tablets or capsules or a 34-day supply, whichever is greater.
Using Our Mail Order Service:
- Send an order form and the prescription along with your coinsurance amount to the address listed on the mail order service form.
- Prescription drugs furnished by mail order will be limited to a 90-day supply per purchase, except that certain drugs, including but not limited to antidepressants, narcotics, and medications for ulcers and HIV disease may be limited to a lesser supply as indicated on your prescription or as required by the Company.
- Drugs requiring continuous refrigeration may not be available through mail order service.
Prescription drugs (including oral contraceptives) and other covered items will be provided as described below after you have paid the specified coinsurance amount. Benefits will be subject to any applicable waiting periods, limitations and exclusions, except that prescription drugs benefits will not be subject to the coordination of benefits provisions or to any deductible or stoploss described in this plan.
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FORMULARY |
A formulary is a list of selected generic and brand-name preferred drugs, which is established, reviewed, and updated routinely by the Company. All drugs are reviewed and selected for inclusion in the Company's formulary by an outside committee of providers, including physicians and pharmacists. Drugs are selected based on published scientific evidence. If clinical data show several drugs are equally effective, the committee usually chooses the most cost effective ones.
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COPAY |
You will be responsible for paying the coinsurance percentage specified below for each covered prescription or refill.
Participating Pharmacies....................50%
Mail Order Service..............................50%
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BENEFIT MAXIMUM |
Benefits for prescription drugs will be provided to an annual maximum of $2,000 per member per calendar year.
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Covered Items: Prescription drugs, which are included in the Company's current drug formulary, will be covered when medically necessary for the treatment of an illness, accidental injury, or disability covered under this plan, subject to all provisions described below. Providers may request coverage of drugs not included in the current drug formulary by calling the Company. Other items covered under this benefit and requiring a prescription include:
- Legend vitamins for prenatal care.
- Smoking cessation prescription drugs and medications, limited to a 90-day lifetime maximum supply.
- Diabetic supplies, including insulin and insulin syringes.
- Oral contraceptive drugs will be provided for a single copay per prepackaged monthly cycle. A maximum of three prepackaged monthly cycles may be purchased at one time for one copay per monthly cycle.
Limitations: Benefits for prescription drugs and other covered items will be limited as follows:
- Prescription drugs must be included in the drug formulary of approved medications established by the Company.
- Prescription drugs must be prescribed by a provider covered under the plan who is acting within the scope of his or her license.
- Prescription drugs related to transplants are covered under this Prescription Drugs Benefit; however, claims for such drugs will be applied to and are subject to the Transplants Benefit maximum of the plan.
- Certain drugs, including but not limited to some antibiotics, inhalers, injectables, Imitrex tablets, diabetes test strips, and drugs defined as controlled substances by federal law, may be limited to a lesser supply as indicated on your prescription or as determined by the Company. Participating pharmacies have been provided with a list of those drugs and our web site formulary also provides this information.
- The Company may require you to obtain all prescriptions from a single participating pharmacy.
Exclusions: The following items are not covered under this Prescription Drugs Benefit due to contract exclusions or, as noted, covered under another benefit of the plan:
- Any items limited or excluded by the medical plan, except where specifically provided.
- Appetite suppressants and drugs for weight loss.
- Drugs or medications used for cosmetic purposes.
- Drugs dispensed by a non-participating pharmacy, except when specifically provided for cases of emergency or outside the service area.
- Any drugs or items obtained from a participating pharmacy when you fail to present the identification card.
- Over-the-counter medications (OTC) and any prescription medication with the same active ingredients as an over-the-counter product.
- Replacement prescriptions resulting from loss, theft, or breakage.
- Oral progesterone compounded products.
- Any drugs or items in excess of the specific limits described above.
This is a brief description of the prescription drugs benefit for Individual Selections and Preferred plans; it is not a certificate of coverage.
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E-mail us for more information and a free quote or CALL TOLL FREE
1-800-875-4490 (in the U.S.)
or 1-253-854-0199 (outside the U.S.)
Fax: 1-253-896-9411
Mailing address: Maddock & Associates, 1407 Willow Road E, Suite C, Tacoma, WA 98424
Serving all of Washington at 800-875-4490, Seattle at 206-682-1628,
Bellevue at 425-454-6834, Kent at 253-854-0199 and Tacoma at 253-572-3291.
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