445-3919_vantpi2805.fm

YOUR BENEFITS
Optimum Choice, Inc.
A UnitedHealthcare Company
Pharmacy Management Program Plan I28
UnitedHealthcare's pharmacy management program provides clinical
pharmacy services that promote choice, accessibility and value. The program offers a broad network of pharmacies (more than 56,000 nationwide*) to provide convenient access to medications.
Most pharmacies participate in our network. However to confirm network participation for a particular pharmacy, we suggest that you first check with your pharmacist or visit our online pharmacy service at www.myuhc.com. The online service offers you home delivery of prescriptions, the ability to view personal benefit coverage and provides you with access to health and well being information, and even location of network retail neighborhood pharmacies by zip code.
Copayment per Prescription Order or RefillYour Copayment is determined by the tier to which the Prescription Drug List Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Please access www.myuhc.com through the Internet, or call the Customer Service number on your ID card to determine tier status.
For a single Copayment, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to additional supply limits. You are responsible for paying the lower of the applicable Copayment or the retail Network Pharmacy's Usual and Customary Charge, or the lower of the applicable Copayment or the Home Delivery Pharmacy's Prescription Drug Cost.
Also note that some Prescription Drug Products require that you notify us in advance to determine whether the Prescription Drug Product meets the definition of a Covered Health Service and is not Experimental, Investigational or Unproven.
*Source: Medco Health Solutions, Inc.
Home Delivery Network
Retail Network Pharmacy
Pharmacy
Optimum Choice, Inc.
Annual Drug
Deductible
Out-of-Pocket Drug
ExclusionsExclusions from coverage listed in the Certificate apply also to this Rider. In Any product dispensed for the purpose of appetite suppression and other weight addition, the following exclusions apply: Outpatient Prescription Drug Products obtained from a non-Network Pharmacy. A specialty medication Prescription Drug Product (such as immunizations and However, if the non-Network Pharmacy has notified us that it agrees to accept allergy serum) which, due to its characteristics as determined by us, must typically reimbursement at the rate applicable to Network Pharmacies, including any be administered or supervised by a qualified provider or licensed/certified health applicable Copayment, as payment in full, you may receive Benefits on the same professional in an outpatient setting. This exclusion does not apply to Depo basis and at the same Copayment level as you would from a Network Pharmacy.
Provera and other injectable drugs used for contraception.
Coverage for Prescription Drug Products for the amount dispensed (days' supply or Durable Medical Equipment. Prescribed and non-prescribed outpatient supplies, quantity limit) which exceeds the supply limit. However, even if the supply limit is other than the diabetic supplies and inhaler spacers specifically stated as covered.
exceeded, Benefits are provided for any drug approved by the FDA for use in the General vitamins, except the following which require a Prescription Order or treatment of cancer pain if the prescription in excess of the supply limit has been Refill: prenatal vitamins, vitamins with fluoride, and single entity vitamins.
prescribed for a patient with intractable cancer pain.
Unit dose packaging of Prescription Drug Products.
Prescription Drug Products dispensed outside the United States, except as required for Emergency treatment.
Medications used for cosmetic purposes.
Drugs which are prescribed, dispensed or intended for use while you are an Prescription Drug Products, including New Prescription Drug Products or new inpatient in a Hospital, Skilled Nursing Facility, or Alternate Facility.
dosage forms, that are determined to not be a Covered Health Service.
Experimental, Investigational or Unproven Services and medications; medications Prescription Drug Products as a replacement for a previously dispensed used for experimental indications and/or dosage regimens determined by us to be Prescription Drug Product that was lost, stolen, broken or destroyed.
experimental, investigational or unproven.There are two exceptions: No prescribed Prescription Drug Products used to treat infertility, except clomiphene. drug shall be excluded as Experimental, Investigational or Unproven on the basis Notwithstanding this exclusion, if in vitro fertilization is covered under the medical that the drug has not been approved by the Food and Drug Administration (FDA) benefits, and the procedure has been authorized, Prescription Drug Products for the treatment of the specific condition for which the drug has been prescribed, associated with its procedure are covered.
provided that: 1) the drug has been approved by the FDA for at least one indication Drugs available over-the-counter that do not require a Prescription Order or Refill and 2) the drug has been recognized as safe and effective for treatment of the by federal or state law before being dispensed. Any Prescription Drug Product that specific condition in one of the standard reference compendia or in substantially is therapeutically equivalent to an over-the-counter drug. Prescription Drug accepted peer-reviewed medical literature; and Benefits for any drug approved by Products that are comprised of components that are available in over-the-counter the FDA for use in the treatment of cancer are covered even if the drug has not been approved by the United States Food and Drug Administration for the Prescription Drug Products for smoking cessation.
treatment of the specific type of cancer for which the drug has been prescribed, provided the drug has been recognized as safe and effective for treatment of that Compounded drugs that do not contain at least one ingredient that requires a specific type of cancer in any of the standard reference compendia. "Peer-reviewed Prescription Order or Refill. Compounded drugs that contain at least one ingredient medical literature" means a scientific study published only after having been that requires a Prescription Order or Refill are assigned to Tier 3.
critically reviewed for scientific accuracy, validity, and reliability by unbiased New Prescription Drug Products and/or new dosage forms until the date they are independent experts in a journal that has been determined by the International reviewed and assigned to a tier by our Prescription Drug List Management Committee of Medical Journal Editors to have met the Uniform Requirements for Committee except that such review and approval of new Prescription Drug Manuscripts submitted to biomedical journals. Peer-reviewed medical literature Products and/or new dosage forms will not be required for any drug prescribed to does not include publications or supplements to publications that are sponsored to treat a covered indication so long as the drug has been approved by the United a significant extent by a pharmaceutical manufacturing company or health carrier. States Food and Drug Administration for at least one indication and the drug is "Standard reference compendia" means the American Medical Association Drug recognized for treatment of the covered indication in one of the standard reference Evaluations, the American Hospital Formulary Service Drug Information, or the compendia or in substantially accepted peer-reviewed medical literature. The United States Pharmacopoeia Dispensing Information.
standard reference compendia are noted above under the Experimental, Prescription Drug Products furnished by the local, state or federal government. Investigational or Unproven Services Exclusion.
Any Prescription Drug Product to the extent payment or benefits are provided or Growth hormone therapy for children with familial short stature (short stature available from the local, state or federal government (for example, Medicare) based upon heredity and not caused by a diagnosed medical condition).
whether or not payment or benefits are received, except as otherwise provided by Prescription Drug Products for any condition, Injury, Sickness or mental illness arising out of, or in the course of, employment for which benefits are available under any workers’ compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received.
This summary of Benefits is intended only to highlight your Benefits for outpatient Prescription Drug Products and should not be relied upon to determine coverage. Your plan may not cover all your outpatient prescription drug expenses. Please refer to your Outpatient Prescription Drug Rider and the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in any way with the Outpatient Prescription Drug Rider or the Certificate of Coverage, the Outpatient Prescription Drug Rider and Certificate of Coverage prevail. Capitalized terms in the Benefit Summary are defined in the Outpatient Prescription Drug Rider and/or Certificate of Coverage.
05H_BS_RX_NET

Source: http://www.rrj.state.va.us/Plan%20I28%20Rx.pdf