Res 1988-077 - Laserfiche WebLink

Home Browse Search

1.8 "Prescription Order" means the authorization for Prescription Medication issued by a Participating Physician, or non-participating Physician rendering THP approved referral or emergency health services, who is duly licensed to make such an authorization in the ordinary course of the physician's professional practice. 2. BENEFITS & MEMBER COST The Prescription Drug Benefits provided under the Rider shall be available for Covered ~rugs dispensed pursuant to a Prescription Order for the out- of-hospital use of the Covered Person; issued by a THP Participating Physician, or a non-participating Physician if authorized and/or approved by THP unless an emergency; and subject to the Health Plan Formulary. 2. 1 The Participating Pharmacy will furnish such Covered Drugs without charge except for the copayment of $4.00 for each Prescription Order and/or refill. In addition to the $4.00 copayment, Covered Persons shall pay to Participating Pharmacies 100% of the additional cost for any Prescription Medication beyond the cost of its generic equivalent, subject to the Drug Product Selection List which at the request of the Covered Person or Participating Physician has been dispensed in place of a medication on the Health Plan Drug Formulary. In addition, if a Covered Person requests a non-formulary medication, physician will indicate on face of Prescription Order "Patient Request" and Covered Person will pay 100% of the cost to the Participating Pharmacy. 2.2 Non-Participating Pharmacies: The Covered Person upon submission of proof of payment acceptable to THP shall be entitled to reimbursement from THP in the amount not to exceed 100% of the usual and customary charges less the $4.00 copayment. The Covered Person will be entitled to such reimbursement only if the following conditions are met: A. The Covered Drug was purchased subsequent to a Prescription Order, or a prescription authorized and/or approved by a Physician describd in Section 1, Part 1.6 or 1.8. B. The Covered Person's life or health would have been endangered had purchasing the Covered Drug been delayed until it could be obtained from a Participating Pharmacy or the Covered Drug was not available from a Participating Pharmacy. C. The Covered Person's reimbursement is requested by submi tted receipt for Covered Drug and request is received by THP within thirty (30) days of the date of proof of purchase. 2.3 Substitutions of generically equivalent drugs will be made by the Pharmacy unless as provided under Item 2.1, above. 3. LIMITATIONS 3.1 Pharmacy need not dispense a Prescription Order which, Pharmacist's professional judgment, should not be filled. in the THPRX 10/87 -2-