2021 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 49
PRESCRIPTION DRUG CARD PROGRAM
Eligible expenses include Prescription Drugs and medicines prescribed in writing by a Physician and dispensed by
a licensed pharmacist, which are deemed necessary for treatment of an Illness or Injury including but not limited
to: insulin; hypodermic needles or syringes, but only when dispensed upon a written prescription of a licensed
Physician, diabetic supplies; smoking deterrents (prescription and over-the-counter).
When your prescription is filled at a retail pharmacy, the maximum amount or quantity of Prescription Drugs covered
per Copay is a 34-day supply or 100-unit dose (whichever is greater).
Expenses for injectables that are not covered under the Prescription Drug Card Program and are Medically
Necessary for the treatment of a covered Illness or Injury will be payable under this Medical Plan subject to any
applicable major medical Network Deductibles and Coinsurance as well as any coverage limitations and exclusions
applicable to the major medical component of the Medical Plan. Please refer to the Eligible Medical Expenses
and the General Limitations and Exclusions section of the Medical Plan.
There is no Coordination of Benefits for prescription drug charges.
NOTE: Coverage, limitations and exclusions for Prescription Drugs will be determined through the
Prescription Drug Card Program elected by the Medical Plan Sponsor and will not be subject to any
limitations and exclusions under the major medical component of the Medical Plan (except for injectables
that are not covered under the Prescription Drug Card Program). For a complete listing of Prescription
Drugs available under the Prescription Drug Card Program, as well as any exclusions or limitations that
may apply, please contact the Prescription Drug Card Program Manager identified in the General Group
Health Plan Information section of this Group Health Care Plan.
Brand Name Drug: Means a trade name medication.
Generic Drug: A Prescription Drug which has the equivalency of the Brand Name Drug with the same use and
metabolic disintegration. This Medical Plan will consider as a Generic Drug any Food and Drug Administration
approved generic pharmaceutical dispensed according to the professional standards of a licensed pharmacist and
clearly designated by the pharmacist as being generic.
Prescription Drug: Any of the following: (a) a Food and Drug Administration-approved drug or medicine, which,
under federal law, is required to bear the legend, “Caution: federal law prohibits dispensing without prescription”;
(b) injectable insulin; or (c) hypodermic needles or syringes, but only when dispensed upon a written prescription
of a licensed Physician. Such drug must be Medically Necessary in the treatment of an Illness or Injury.
Claim Determination / Appeal of Prescription Drug Claims
In the event you receive an Adverse Determination following a request for coverage of a prescription benefit claim,
you have the right to appeal the Adverse Determination in writing within 180 days of receipt of notice of the initial
coverage decision. To initiate an appeal for coverage, you or your Authorized Representative (such as your
Physician), must provide in writing, your name, member ID, phone number, the Prescription Drug for which benefit
coverage has been denied and any additional information that may be relevant to your appeal. This information
should be mailed to Optum Rx, P.O. Box 9472, Minneapolis, MN 55440-9472. You may call Optum Rx at 855-8969779, if you have any questions. A decision regarding your appeal will be sent to you within 15 days of receipt of
your written request. The notice will include the specific reasons for the decision and the plan provisions on which
the decision is based. You have the right to receive, upon request and at no charge, the information used to review
If you are not satisfied with the coverage decision made on appeal, you may request in writing, within 90 days of
the receipt of notice of the decision, a second level appeal. To initiate a second level appeal, you or your authorized
representative (such as your Physician), must provide in writing, your name, member ID, phone number, the
Prescription Drug for which benefit coverage has been denied and any additional information that may be relevant
to your appeal. This information should be mailed to Optum Rx, P.O. Box 9472, Minneapolis, MN 55440-9472. You
may call Optum Rx at 855-896-9779, if you have any questions. A decision regarding your request will be sent to
you in writing within 15 days of receipt of your written request for appeal. You have the right to receive, upon request