BENEFIT LANGUAGE WRITING SAMPLE

by Dean Blake

This prescription drug rider was drafted by me for Med One Health Plan of Nevada. Language in [red square brackets] is variable language and a convention used when submitting policy language for approval by the department of insurance.

Allianz Life Insurance Company of North America

1750 Hennepin Avenue South
Minneapolis, Minnesota 55403-2195

PRESCRIPTION CARD SERVICE

The Company will pay for Covered Prescription Drugs for an Insured Person or Insured Dependent, subject to Dispensing Limitations, Exclusions and if filled in-network, the Formulary Restrictions. Payment is subject to a Copayment amount per prescription fill or refill(s) in-network pharmacy. [a lower Formulary Copayment Amount when Formulary drugs are dispenses,] or the Annual Deductible and Coinsurance percentage if filled by an out-of-network pharmacy, as shown on the Schedule of Benefits. Amounts paid by Insureds as Copayments in-network are not creditable toward satisfaction of the plan Annual Deductible or Stop-Loss. The name of the prescription card network offering the Copayment amount is shown on the [wallet card] [along with the amount of the Copayment for in-network, and Coinsurance for out-of-network prescription fill and refills.] If the prescription cost is less than the Copayment Amount, only the lesser amount is due.

COVERED PRESCRIPTION DRUGS:

  1. Non-injectable drugs that under federal or state law may only be dispensed upon the prescription of a licensed Physician, and if filled in the in-network pharmacy [must appear in the Formulary][is payable subject to the Formulary Copayment amount][, except that Acute Medications will be filled, and only a one week supply of Chromic Medications will be dispensed unless the Non-participating provider selects a Formulary substitute].
  2. Injectable insulin, and syringes, lancets and chemical strips;
  3. Compound medications of which at least one ingredient is a prescription drug;
  4. Injectable Imitrex;
  5. Medrol, Rocephin [given at the time of an office visit].

DISPENSING LIMITATIONS:

Brand name drugs may be substituted for generics, if not prohibited by the prescribing physician [or law], upon payment of the price differential by the Insured. Prescription fills are limited to a [thirty day] supply, except for certain medical conditions requiring "maintenance medications," in which case a [90 supply] will be periodically dispensed by mail order, subject single composite Copayments or Coinsurance amount, and
  1. Oral contraceptives from the in-network pharmacy obtained in a [90-day] supply;
  2. Creams and ointments - [thirty day] supply [or maximum of ]two[ ounces(compounded ointments and creams limited to ]eight[ ounces), whichever is less];
  3. Drug manufacturers in trade dispensing packages - one trade package, not to exceed other dispensing limitations (not applicable to insulin or the covered injectable drugs);
  4. Insulin - two vials;
  5. Oral liquids - [thirty day] supply [or ]960ml (one quart)[, whichever is less];
  6. Solid dosage - [thirty day] supply [or ]100 (oral tablets and capsules) units[, whichever is less];
  7. Each prescription refill is provided on the same basis as the original prescription.

    EXCLUSIONS:

    1. Drugs that do not require a prescription by law;
    2. Drugs labeled "caution - limited by federal law to investigational use," or experimental drugs, even though a charge is made to the Insured Person or Insured Dependent;
    3. Charges for the administration or injection of any drug;
    4. Drugs when used for cosmetic purposes;
    5. Smoking cessation aids other than smoking cessation patch and gums, when prescribed by a physician as part of an approved smoking cessation program;
    6. Appetite suppressants;
    7. Compound prescriptions of which none of the ingredients requires a prescription;
    8. Drugs for the treatment of infertility, unless determined to be medically necessary by the Utilization Review Department;
    9. Progesterone suppositories, suspensions and troches;
    10. Drugs available over the counter and any prescription drug that is equivalent to an over-the-counter product, except insulin;
    11. Drugs to enhance athletic performance;
    12. Nutritional products when obtained for consumption the than during Hospital confinement;
    13. Replacement Prescription Drugs resulting from less or theft;
    14. Devices of any type, whether or not they require a prescription;
    15. Oral contraceptive obtained from out-of-network pharmacies;
    16. Vitamins; except pre-natal vitamins;
    17. Floride preparations;
    18. Injectable drugs; and
    19. Over-the-counter drugs.

    Form No.: GMM-RXRID-002 Med One Health Plan (REV. 3/1/96)
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    [rxmedone.html]12/30/98