Georgia Health Insurance Prescription Drug Information

Covered Services are stated in the Summary of Benefits. All In-Network prescriptions must be written by either your Primary Care Physician, a Network Physician designated by your Primary are Physician to provide services in his/her absence, an emergency room Physician (if your condition is a Medical Emergency), or a Specialist who is a Network Provider.

Your benefit design as shown in the Summary of Benefits will determine the Copayment of your Prescription Drug Plan for Formulary drugs and non-formulary drugs. Insulin, which can be obtained over the counter, will only be covered under the Prescription Drug benefit when accompanied by a prescription.

Covered Services may include:
Retail Prescription Drugs that have been prescribed by a Network Provider and obtained through a participating pharmacy. Retail Prescription Drugs shall, in all cases, be dispensed according to the Drug Formulary for prescriptions written and filled In-Network. The Drug Formulary may be amended from time to time by BCBSHP.

A Participant or prospective Participant shall be entitled upon request, to a copy of the Drug Formulary Guide, available through the Member Guide or BCBSHP's Website. You may exercise your right to a non-formulary drug by filing a Formulary appeal.

You can obtain, without penalty and in a timely fashion, specific drugs and medications not included in the Formulary when:

• The Formulary's equivalent has been ineffective in the treatment of the patient's disease or condition; or
• The Formulary's drug causes or is reasonably expected to cause adverse or harmful reactions in the patient.

Maintenance Drugs
To determine if a drug is considered a maintenance drug or requires pre-authorization, please call Customer Service. Maintenance drugs are available in a 90-day supply for two Copayments, as outline in the Summary of Benefits.

A limited number of Prescription Drugs require pre-authorization for Medical Necessity. If pre-authorization is not approved, then the designated drug will not be eligible for coverage. To determine if a drug requires pre-authorization, please call Customer Service.

The following are not Covered Services under this Plan:

• Prescription Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule.
• Prescription Drugs received through an Internet pharmacy provider or mail order provider except for the designated mail order provider.
• Non-legend vitamins.
• Smoking cessation products (including the use of Wellbutrin SR for this purpose).
• Over-the-counter items.
• Cosmetic drugs (e.g., Propecia).
• Appetite suppressants (anorexiants).
• Weight loss products.
• Diet supplements.
• Syringes (for use other than insulin).
• Non-contraceptive injectables (except with pre-certification).
• The administration or injection of any Prescription Drug or any drugs or medicines.
• Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued.
• Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order.
• Prescription Drugs for which there is no charge.
• Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use.
• Prescription Drugs for use as an Inpatient or outpatient of a Hospital and Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients.
• Charges for delivery of any Prescription Drugs.
• Drugs and medicines which do not require a prescription order and which are not Prescription Drugs.
• Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs.
• Prescription Drugs which are not Medically Necessary or which the Plan Administrator determines are not consistent with the diagnosis.
• Prescription Drugs which the Plan Administrator determines are not provided in accordance with accepted professional medical standards in the United States.
• Any services or supplies which are not specifically listed as covered under this Prescription Drug Plan.
• Prescription Drugs which are Experimental or Investigational in nature as explained in the "Exclusions" section.
• Vaccines delivered by nasal spray or mist.
• Prescription medicine for nail fungus except for immunocompromised or diabetic patients.