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OUTPATIENT PRESCRIPTION DRUG RIDER
This Rider is issued to the Policyholder on the Group Effective Date or Group Renewal Date and
made a part of the Evidence of Coverage to which it is attached. In case of any conflict between
the terms or provisions of this Rider and the Evidence of Coverage, this Rider controls.
Coventry Health Care of Nebraska, Inc. is hereafter called the “Health Plan,” “We,” “Us,” or
Any Subscriber, Member or Dependent who is enrolled for Coverage under the Evidence of
Coverage, in accordance with its terms and conditions, is hereafter called “You” or “Member.”
Coverage of a Prescription Drug does not constitute any assumption of liability for treatment of a
sickness, injury, or condition, not otherwise Covered in the Evidence of Coverage. COVERED SERVICES
Subject to the Limitations, Exclusions, Member Responsibility and Ancillary Charges described
below, outpatient Prescription Drugs will be Covered under this Rider when:
(a) the Member is eligible to receive Covered Services; (b) Prescription Order or Refill is written by a Prescribing Provider; (c) filled at a pharmacy, including a Maintenance Medication Pharmacy or Specialty
(d) the Member presents their current Member identification card to a Participating Pharmacy.
Generically equivalent pharmaceuticals will be dispensed whenever there is an FDA approved generic drug. If you receive a brand name Prescription Drug when a Generic drug is available, You will be responsible for the Ancillary Charge in addition to Your normal Member Responsibility. The Ancillary Charge will apply 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 average wholesale price of the Prescription Drug.
Deductible Tier 1
Ancillary Charges do not apply
towards this maximum and will
continue to apply after the
maximum has been met
Maximum Lifetime Benefit
*Covered Prescription Drug expenses will apply towards the medical Deductible listed on Your Schedule of Benefits. Once the medical Deductible is met, You will pay the Copayment and/or Coinsurance listed above for Prescription Drugs.
The following rules apply to Prescription Orders and Refills:
(a) Member Responsibility is due each time a Prescription Drug order is filled or refilled, up to
(b) Select over-the-counter medications, as determined by the Health Plan to be equivalent to
prescription dosage strength, will be Covered under this Rider at the Generic Formulary Member Responsibility. Coverage of the selected over-the-counter medications requires a Provider’s prescription.
(c) Only one drug and “Rx Unit” will be dispensed per Prescription Drug fill or refill. The Rx
Unit quantity is determined by FDA labeling, the dosage required or the Health Plan Formulary guidelines. Member Responsibility is required for each Rx Unit, Dispensed Container, or prepackaged item.
(d) If a Prescription Drug is prescribed in a single dosage amount but the version of that
Prescription Drug on the Formulary is not manufactured in such single dosage amount,
then the Member Responsibility will be the same as if the Formulary Prescription Drug was manufactured in such single dose.
(e) Members presently taking a Formulary Prescription Drug shall be notified either
electronically, or in writing at least thirty days prior to any deletions to the Formulary. Notifications will not be provided for generic substitutions.
Retail Participating Pharmacy Benefits
Prescription Drugs not ordered through a Maintenance Medication Pharmacy or Specialty
Pharmacy may be obtained at a retail Participating Pharmacy. Prescription Drugs filled at a
retail Participating Pharmacy are generally limited to a thirty-one (31) day supply per fill.
However, the following may be dispensed at up to a ninety-three (93) day supply:
(a) Insulin and diabetic supplies (insulin syringes, with or without needles, needles, blood and
urine glucose test strips, lancets and devices, ketone test strips and tabs).
Maintenance Medication Benefits
Prescription Drugs determined by the Health Plan to be Maintenance Medications can be filled by
the Maintenance Medication Pharmacy at up to a ninety-three (93) day supply. Maintenance
Medication Pharmacies generally fill a Prescription Order or Refill by mail and may be referred to
as mail order pharmacies. To access a mail order Maintenance Medication Pharmacy, the
Member shall mail the Prescription Order or Refill to the Maintenance Medication Pharmacy in
the designated mail order prescription envelope available on our website:
. Specialty Pharmacy Benefits
Self-Administered Injectable Drugs are Covered under this Rider only when they are obtained
from a Specialty Pharmacy. Your Prescribing Provider will receive instructions on how to initiate
the process with the Specialty Pharmacy when Prior Authorization is obtained. You may also
contact Customer Service at the phone number listed on your ID card for additional support. Non Participating Pharmacy Benefits
A Prescription Order or Refill may be obtained through a Non-Participating Pharmacy, however,
You may be required to pay for the entire cost of the Prescription Drug(s) and file a claim for
reimbursement. Reimbursement for Prescription Drugs will be at a rate consistent with what the
Health Plan reimburses a Participating Pharmacy less Your Member Responsibility amount.
Members must submit claims for reimbursement on a claim form (available from Our agent or
Us) within ninety (90) days of the date of purchase of the Prescription Drugs.
Prescription Drugs prescribed for Emergency Medical Conditions and filled by a Non-
Participating Pharmacy are Covered, in full, only if a Participating Pharmacy was not available. Prior Authorization Requirements
Regardless of where a Prescription Order or Refill is filled, some drugs require Prior
Authorization in order for them to be Covered. These include, but are not limited to,
medications that require special medical tests before use, that are not recommended as a first-line
treatment, or that have a potential misuse or abuse. Prescription Drugs requiring Prior
Authorization are identified within the Formulary with “PA” next to the name of the drug. Quantity Limits
There are general limits on how much of a Prescription Drug may be dispensed by a pharmacy to
fill a Prescription Order or Refill. Unless otherwise provided by this Rider, the quantity of a
Prescription Drug should not exceed that required for the lesser of:
(a) The quantity prescribed in the Prescription Order or Prescription Refill; (b) A thirty-one (31) day supply, excluding Maintenance Medication Pharmacies; (c) The amount determined by Us to be Medically Necessary; or (d) Depending on the form and packaging of the product, the following: The number of
commercially prepackaged items (including but not limited to inhalers, topicals, and vials) needed for thirty-one (31) days of treatment with Member Responsibility applied to each pre-packaged item or container.
To promote appropriate utilization, or following manufacturer’s recommendations, some
Covered Drugs under this Rider may also be subject to Prescription Drug specific quantity limits.
You can get information on specific quantity limits from the searchable Formulary on the
websit or by contacting the Customer Service Department. A hard-copy
of the Formulary is available upon request. Before a Prescription Order or Refill for a drug that
exceeds the specific quantity limit can be filled, the Prescribing Provider must call the Health
Plan and obtain Prior Authorization. DEFINITIONS
Any capitalized terms used in this Rider and not otherwise defined herein shall have the meaning set forth in the Evidence of Coverage. The plural or singular version of each defined word or phrase shall apply the same definition. The following definitions apply for the purposes of this Rider only: 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 the Prescription Drug is subject to the Maximum Allowable Cost and covered at the generic product level. 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 for the Generic Drug. You are responsible at the time of service for payment of the Ancillary Charge directly to the Participating Pharmacy. Coinsurance: The percentage that You are responsible for paying the pharmacy for Covered Drugs. Covered Drugs: Prescription Drugs prescribed by a Prescribing Provider and approved by Us, subject to the specifications listed in this Rider. Dispensed Container:
A Dispensed Container is the single unit of a Prescription Order or Refill when multiple units are
included. If a Prescription Order or Refill is for multiple tubes, bottles, packets, or vials of a Prescription
Drug, the cost sharing amount applies separately to each one of those Dispensed Containers.
A list of specific generic and brand name Prescription Drugs authorized for Coverage by the
Health Plan. This list is subject to periodic review and modification at least annually by the Health
Plan’s Pharmacy and Therapeutics Committee. Since there may be more than one brand name of a
Prescription Drug, not all brands of the same Prescription Drug (e.g., different manufacturers) may
be included in the Formulary. The Formulary is available for review in the searchable Formulary
on Our websitein the Participating Provider’s office, or by contacting the
Customer Service Department at (800) 288-3343. 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 Drug that appears on the Health Plan’s Formulary.
A Prescription Drug prescribed by its generic and chemical name heading according to the
principal ingredient(s) and approved by the Food and Drug Administration.
Maintenance Medication Pharmacy:
A pharmacy (either retail or mail order) that dispenses Maintenance Medications pursuant to a 93
Prescription Drugs, designated by the Plan and not included on the mail-order exclusion list, which
are not written for episodic treatments of medical.
Maximum Allowable Cost:
The price assigned to Prescription Drugs that will be Covered at the Generic product level, subject
to periodic review and modification by the Health Plan.
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 Health Plan’s list of Formulary Prescription Drugs.
Any pharmacy that is not a Participating Pharmacy as defined herein.
A pharmacy licensed in the State in which it is located that has entered into a written contract with
the Health Plan to provide services to the Health Plan’s Members, or on whose behalf a written
contract has been made with the Health Plan which is in effect at the time services are provided.
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).
This definition of Prescription Drug includes 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 Health Plan’s criteria and the product is not available commercially.
Prescription Drug Deductible:
The amount, which must be satisfied each Benefit Year, before Covered Drugs are payable under this
Rider. The dollar amount applied to the Deductible is based on the dollar amount that We pay
Participating Pharmacies for filling a Prescription Order or Refill. You are responsible at the time
of service for payment of the Prescription Drug Deductible directly to the pharmacy, until your
Deductible is met. The Prescription Drug Deductible will not carry over to the next Benefit Year.
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.
A process where the Health Plan or its designee determines, prior to dispensing, that a Prescription
Order or Refill, otherwise Covered under this Rider, has been reviewed and, based upon
information provided by the Prescribing Provider, the Prescription Order or Refill satisfies the
requirements for Coverage.
Self-Administered Injectable Drug(s):
Self-Administered Injectable Prescription Drugs, as defined by the Health Plan, are commonly and
customarily administered by the Member, and are available through a Specialty Pharmacy.
Examples of Self-Administered Injectable Prescription Drugs include, but are not limited to, the
following: multiple sclerosis agents, growth hormones, colony stimulating factors given more than
once monthly, chronic medications for hepatitis C, certain rheumatoid arthritis medications, certain
injectable HIV drugs, certain osteoporosis agents, and heparin products.
Note: For definition purposes, other injectable drugs, that may be acquired through a retail
pharmacy, are not considered Self-Administered Injectable Prescription Drugs, such as: insulin,
glucagon, bee sting kits, Imitrex and injectable contraceptives.
A pharmacy that is designated as a Specialty Pharmacy by the Health Plan for Self-Administered
Injectable Drug Prescription Orders or Refills.
1. A Prescription Order or Refill will not be provided after the lesser of:
a.) twelve (12) months from the original date on the Prescription Order or Refill; or b.) 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 Self-Administered Injectable Drugs as determined by
the Health Plan and insulin, glucagon, bee sting kits, Imitrex and injectable contraceptives that are commonly and customarily administered by the Member.
4. Selected products 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 Prior Authorization by the Health Plan and may not be available through the Maintenance Medication Pharmacy program.
5. The pharmacy shall not dispense a Prescription Drug order which, in the Pharmacist’s
professional judgment, should not be filled.
6. The Health Plan reserves the right to include only one (1) Prescription Drug on its Formulary
when the same Prescription Drug is made or sold under two or more different names. The Prescription Drug that is listed on the Formulary will be Covered in accordance with the level on which it is listed on the Formulary. The Prescription Drug(s) that is/are not listed on the Formulary will be Covered at the Non-Formulary Member Responsibility.
7. The Health Plan reserves 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 appropriate Member Responsibility. The product or products in forms or dosages not listed on the Formulary will not be Covered.
8. Coverage of therapeutic devices or supplies requiring a Prescription Order and prescribed by a
Prescribing Provider is limited to Health Plan approved devices, supplies, or spacers for metered dose inhalers.
9. Coverage through a mail order Maintenance Medication Pharmacy is not available on drugs
that cannot be shipped by mail due to state or federal laws or regulations, or when the Health 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. There is no coordination of benefits for outpatient Prescriptions Drugs with other health plans,
The following are Excluded
from Coverage under this Rider:
1. Prescription Drugs related to the treatment of a non-Covered Service as further described in the
Evidence of Coverage (i.e. dental services).
2. Prescription Drugs that are determined by Us to be not Medically Necessary. The Health Plan
reserves the right to require medical Prior Authorization for selected drugs before providing Coverage.
3. Prescription Drugs that are Experimental or Investigational, including: FDA approved drugs
used for off-label indications, (except as required by state law); drugs labeled “Caution-limited by Federal Law to Investigational Use”; drugs prescribed at investigational doses; drugs with no FDA approved indications and drugs given as a part of a study.
4. Any Prescription Drug which is to be administered, in whole or in part, while You are in a
Hospital, Physicians office or other health care facility.
5. 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.
6. Vitamins and minerals (both over-the-counter and legend), except legend prenatal vitamins,
and liquid or chewable legend pediatric vitamins as specified on the Formulary. Coverage requires an order from a Prescribing Provider.
7. Injectable medications and Self-Administered Injectable Drugs, except those designated by the
8. 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 on the Formulary and obtained from a pharmacy with a Prescribing Provider’s prescription. Also excluded are Prescription Medications that have an over-the-counter equivalent or alternatives, unless otherwise specified on the Formulary.
9. Devices or supplies of any type, even though requiring a Prescription Order, including but not
limited to, therapeutic devices, support garments, corrective appliances, non-disposable hypodermic needles, syringes or other devices, regardless of their intended use.
10. Implantable time-released Prescription Drug (e.g., Eligard or Zoladex); 11. 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.
12. Anti-smoking medication or smoking cessation devices. 13. Prescription Drugs used to treat chemical dependency and/or substance abuse.
14. Drugs used primarily for hair restoration. 15. Pharmacological therapy for weight reduction, dietary supplements, appetite suppressants, and
other drugs used to treat obesity, morbid obesity or assist in weight reduction.
16. Drugs, oral or injectable, used for the primary purpose of, or in connection with, treating
infertility, fertilization, and/or artificial insemination.
17. Medications used for Cosmetic purposes or to enhance athletic performance (i.e. 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.).
18. Prescription Drugs dispensed in unit doses when bulk packaging is available or repackaged
19. Replacement for lost, destroyed or stolen Prescription Drugs. 20. Duplicate drug therapy (i.e. two antihistamine drugs). 21. Oral dental preparations and fluoride rinses, except pediatric fluoride tablets or drops as
22. Prescription Drugs 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 Health 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 Health 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.
3. The Health Plan may utilize Prescription Drug rebates as a mechanism to reduce Prescription
Drug costs. Member shall not share in any retrospective volume-based discounts or rebates. However, such rebates will be considered, in the aggregate, in Health Plan's prospective premium calculations.
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Older People’s JSNA Factsheet : Mental Health Summary This factsheet covers mainly dementia and depression. Around 1800 people are estimated to have dementia in Southwark. Prevalence rises steeply with age. Under half of people with dementia over 65 appear to be recognised (on registers) with local GPs. Dementia may be a precipitating factor in admission, for example when the person