Distinct Advantage – PPO
Plan 3 – 2500(40)97
Attachment A Benefit Schedule
This Plan does not include maternity coverage.
Lifetime Maximum Benefit for all Covered
Services: $2,000,000 of Eligible Medical
Expenses (“EME”).
Calendar Year Deductible (“CYD”): $2,500 per
Insured and $5,000 per family. The CYD is a
combined total of Plan and Non-Plan EME. The
CYD does not accumulate toward the Calendar
Year Coinsurance Maximum.
Please read your SHL Agreement of Coverage to
understand how EME payments to Providers are
determined. Plan Providers have agreed to accept
SHL’s Reimbursement Schedule as payment in
full for Covered Services, less any applicable
CYD, Copayments and/or Coinsurance due from
the Insured.
Coinsurance: After satisfying your CYD, your
Coinsurance for most Plan Provider services is
10% of EME. Your Coinsurance for most
Non-Plan Provider services is 30% of EME.
(Please reference the following pages for specific
Coinsurance responsibilities).
Coinsurance Maximum: After satisfying your
CYD, your Coinsurance is limited to a maximum of
$2,500 of EME per Insured per Calendar Year
($5,000 per family) when using Plan Providers,
and $5,000 of EME per Insured per Calendar Year
($10,000 per family) when using Non-Plan
Providers.
Form No. SHL-IndDAP-masBS-2005
Page 1
Important Note: You are responsible for all
amounts exceeding the applicable benefit
maximums, EME payments to Non-Plan
Providers, and penalties for not complying with the
Managed Care Program. Please reference the
following pages for specific Coinsurance
responsibilities.
(NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3
Legal Documents
In no event will the Coinsurance Maximum exceed
$7,500 of EME per Insured per Calendar Year
($15,000 per family). The Coinsurance Maximum
does not include Copayments, Prescription Drug
Fees, or CYD.
Benefit Schedule
Covered Services and
Limitations
Prior
Auth
Required
Plan
Provider
Benefits(1)
Medical - Physician Services and
Physician Consultations
Non-Plan
Provider
Benefits(1)
After CYD, SHL pays
70% of EME.
Office Visit/Consultations
Includes routine lab and x-ray services
provided and billed by the Physician’s
office.
No
Insured pays $40
per visit.
Inpatient Visit/Consultations
Yes
After CYD, SHL
pays 90% of EME.
Preventive Healthcare Services
Includes routine lab and x-ray services
provided and billed by the Physician’s
office.
No
Insured pays $40
per visit. Subject to
the maximum
benefit.
After CYD, SHL pays
70% of EME.
Subject to the
maximum benefit.
Laboratory Services - Outpatient
Yes
After CYD, SHL pays
90% of EME.
After CYD, SHL pays
70% of EME.
Routine Radiological and NonRadiological Diagnostic Imaging
Services - Outpatient
Yes
After CYD, SHL pays
90% of EME.
After CYD, SHL pays
70% of EME.
Maximum benefit is $500 per Calendar
Year.
After CYD, SHL pays
70% of EME.
Emergency Services
Urgent Care Facility
No
Insured pays $55
per visit.
Physician’s Services in Emergency
Room
No
After CYD, SHL
pays 90% of EME.
Emergency Room Facility
No
After CYD, SHL
pays 90% of EME.
Hospital Admission – Emergency
Stabilization
Applies until patient is stabilized and
safe for transfer as determined by the
attending Physician.
No
After CYD, SHL
pays 90% of EME.
Maximum benefit for Medically
Necessary but Non-Emergency
Services received in an emergency
room is 50% of EME.
Form No. SHL-IndDAP-masBS-2005
Page 2
(NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3
Benefit Schedule
Covered Services and
Limitations
Prior
Auth
Required
Plan
Provider
Benefits(1)
Non-Plan
Provider
Benefits(1)
Ambulance Services
Emergency – Ground Transport
No
After CYD, SHL
pays 90% of EME
per trip.
After CYD, SHL
pays 70% of EME
per trip.
Emergency – Air Transport
No
After CYD, SHL
pays 50% of EME
per trip.
After CYD, SHL
pays 50% of EME
per trip.
SHL Arranged Transfers
Yes
No charge per trip.
No charge per trip.
Inpatient Hospital Facility Services
Elective and Emergency poststabilization admission.
Yes
After CYD, SHL pays
90% of EME.
After CYD, SHL pays
70% of EME.
Outpatient Hospital Facility and
Ambulatory Surgical Facility
Services, includes Sterilization
Yes
After CYD, SHL pays
90% of EME.
After CYD, SHL pays
70% of EME.
Inpatient Hospital Facility
Yes
After CYD, SHL
pays 90% of EME.
Outpatient Hospital Facility
Yes
After CYD, SHL
pays 90% of EME.
Physician’s Office (In addition to office
visit Copayment and/or Coinsurance.)
Yes
Insured pays $40
per visit.
Assistant Surgical Services
Yes
After CYD, SHL pays
90% of EME.
After CYD, SHL pays
70% of EME.
Anesthesia Services
Yes
After CYD, SHL pays
90% of EME.
After CYD, SHL pays
70% of EME.
Yes
After CYD, SHL
pays 50% of EME.
Subject to the
Maximum benefit.
After CYD, SHL
pays 50% of EME.
Subject to the
maximum benefit.
Gastric Restrictive Surgical Services
Physician Surgical Services
The maximum lifetime benefit for all
Gastric Restrictive Surgical Services
is $5,000 per Insured.
Form No. SHL-IndDAP-masBS-2005
Page 3
(NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3
Legal Documents
After CYD, SHL pays
70% of EME.
Inpatient and Outpatient Physician
Surgical Services, includes
Sterilization
Benefit Schedule
Covered Services and
Limitations
Prior
Auth
Required
Plan
Provider
Benefits(1)
Non-Plan
Provider
Benefits(1)
Gastric Restrictive Surgical Services
(continued)
Complications
The maximum lifetime benefit for all
complications in connection with
Gastric Restrictive Surgical Services
is $5,000 per Insured.
Yes
Mastectomy Reconstructive
Surgical Services
Physician Surgical Services
Yes
Prosthetic Devices for Mastectomy
Reconstruction – Unlimited.
Yes
After CYD, SHL
50 pays % of EME.
Subject to the
maximum benefit.
After CYD, SHL
pays 50% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
90% of EME.
After CYD, SHL pays
70% of EME.
After CYD, SHL pays
70% of EME.
Oral Surgical Services
Office Visit
Yes
Insured pays $40
per visit.
Physician Surgical Services
• Inpatient Hospital Facility
Yes
After CYD, SHL
pays 90% of EME.
•
Yes
After CYD, SHL
pays 90% of EME.
Inpatient Hospital Facility Services
Yes
After CYD, SHL
pays 90% of EME.
After CYD, SHL
pays 70% of EME.
Physician Surgical Services
Yes
After CYD, SHL
pays 90% of EME.
After CYD, SHL
pays 70% of EME.
Transportation, Lodging and Meals
The maximum benefit per Insured per
Transplant Benefit Period for
transportation, lodging and meals is
$10,000. The maximum daily limit for
lodging and meals is $200.
Yes
After CYD, SHL
pays 90% of EME.
Subject to the
maximum benefit.
After CYD, SHL
pays 70% of EME.
Subject to the
maximum benefit.
Outpatient Hospital Facility
Organ and Tissue Transplant
Surgical Services
Form No. SHL-IndDAP-masBS-2005
Page 4
(NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3
Benefit Schedule
Covered Services and
Limitations
Prior
Auth
Required
Plan
Provider
Benefits(1)
Non-Plan
Provider
Benefits(1)
Organ and Tissue Transplant
Surgical Services (continued)
Procurement
The maximum benefit per Insured per
Transplant Benefit Period for
procurement of the organ/tissue is
$15,000 of EME.
Yes
After CYD, SHL
pays 90% of EME.
Subject to the
maximum benefit.
After CYD, SHL
pays 70% of EME.
Subject to the
maximum benefit.
Retransplantation Services
The 50% of EME for Retransplantation
Services does not apply towards your
Calendar Year Coinsurance maximum.
Yes
After CYD, SHL
pays 50% of EME.
Subject to the
maximum benefit.
After CYD, SHL
pays 50% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
90% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
70% of EME.
Subject to the
Maximum benefit.
The maximum lifetime benefit that will
be paid for an Insured for all Covered
Transplant Procedures combined is
$100,000.
Physician House Calls
Yes
Home Care Services
Yes
Private Duty Nurse
Yes
Maximum benefit is limited to $5,000
per Insured per Calendar Year.
Hospice Care Services
Inpatient Hospice Services
Yes
After CYD, SHL
pays 90% of EME.
After CYD, SHL
pays 70% of EME.
Outpatient Hospice Services
Yes
After CYD, SHL
pays 90% of EME.
After CYD, SHL
pays 70% of EME.
Inpatient Respite Services
Limited to $1,500 per Insured per
Calendar Year.
Yes
After CYD, SHL
pays 90% of EME.
Subject to the
Maximum benefit.
After CYD, SHL
pays 70% of EME.
Subject to the
maximum benefit.
Form No. SHL-IndDAP-masBS-2005
Page 5
(NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3
Legal Documents
Home Healthcare Services
Refer to your outpatient Prescription
Drug Benefit Rider, if applicable, for
your outpatient self-injectable covered
drug benefit.
Benefit Schedule
Covered Services and
Limitations
Prior
Auth
Required
Plan
Provider
Benefits(1)
Non-Plan
Provider
Benefits(1)
Hospice Care Services (continued)
Outpatient Respite Services
Limited to $1,000 per Insured per
Calendar Year.
Yes
After CYD, SHL
pays 90% of EME.
Subject to the
maximum benefit.
After CYD, SHL
pays 70% of EME.
Subject to the
maximum benefit.
Bereavement Services
Limited to five (5) group therapy
sessions or $500 per Insured,
whichever is less. Treatment must be
completed within six (6) months of the
date of death.
Yes
After CYD, SHL
pays 90% of EME.
Subject to the
maximum benefit.
After CYD, SHL
pays 70% of EME.
Subject to the
maximum benefit.
Skilled Nursing Facility
Maximum benefit is $3,500 per Insured
per Calendar Year.
Yes
After CYD, SHL pays
90% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
70% of EME.
Subject to the
maximum benefit.
Manual Manipulation (except for
reduction of fractures or dislocation)
Maximum benefit is $500 per Insured
per Calendar Year and $5,000 per
lifetime.
Yes
After CYD, SHL pays
90% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
70% of EME.
Subject to the
Maximum benefit.
After CYD, SHL pays
90% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
70% of EME.
Subject to the
maximum benefit.
Short-Term Rehabilitation
Services
Inpatient Hospital Facility or Skilled
Nursing Facility
Maximum benefit is $20,000 per
Insured per Calendar Year.
Yes
Outpatient Hospital Facility
Maximum benefit is $2,500 per Insured
per Calendar Year.
Yes
Genetic Disease Testing Services
Includes Inpatient, outpatient and
independent laboratory services.
Yes
After CYD, SHL pays
50% of EME per
test.
After CYD, SHL pays
50% of EME per
test.
Infertility Office Visit Evaluation
Please refer to Covered Services
Copayments and/or Coinsurance
amounts for any infertility procedures
performed.
Yes
Insured pays $40
per visit.
After CYD, SHL pays
70% of EME.
Form No. SHL-IndDAP-masBS-2005
Page 6
(NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3
Benefit Schedule
Covered Services and
Limitations
Medical Supplies
Prior
Auth
Required
Plan
Provider
Benefits(1)
Non-Plan
Provider
Benefits(1)
Yes
After CYD, SHL pays
90% of EME.
After CYD, SHL pays
70% of EME.
After CYD, SHL pays
90% of EME.
After CYD, SHL pays
70% of EME.
After CYD, SHL
pays 50% of EME
per test
After CYD, SHL pays
90% of EME.
Subject to the
maximum benefit.
After CYD, SHL
Pays 50% of EME
Per test
After CYD, SHL pays
70% of EME.
Subject to the
Maximum benefit.
Other Diagnostic and Therapeutic
Services
Yes
Amniocentesis
Yes
Anti-cancer drug therapy, non-cancer
related intravenous injection therapy or
other Medically Necessary intravenous
therapeutic services.
Yes
Dialysis
Yes
Other services such as:
• complex diagnostic imaging
(i.e., CAT scan, MRI);
• complex neurological or psychiatric
testing or therapeutic services;
• pulmonary diagnostic services;
• vascular diagnostic and therapeutic
services.
Yes
Otologic Evaluations
Yes
Therapeutic Radiology
Yes
Positron Emission Tomography (PET)
Scans
Yes
Prosthetics, Orthotic Devices and
Durable Medical Equipment
DME benefit includes rental or
purchase at SHL’s option.
Yes
Legal Documents
Allergy Testing/Serum Injections
Lifetime maximum benefit per Insured
is $10,000 for Prosthetics, Orthotics
and Durable Medical Equipment
combined.
After CYD, SHL pays
70% of EME.
Self-Management and Treatment
of Diabetes
Education and Training
Form No. SHL-IndDAP-masBS-2005
No
Page 7
Insured pays $40
per visit.
(NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3
Benefit Schedule
Covered Services and
Limitations
Prior
Auth
Required
Plan
Provider
Benefits(1)
Self-Management and Treatment
of Diabetes (continued)
Non-Plan
Provider
Benefits(1)
After CYD, SHL pays
70% of EME.
Supplies (except for Insulin Pump
Supplies)
No
Insured pays $5 per
therapeutic supply.
•
Yes
Insured pays $40
per therapeutic
supply.
Equipment (except for Insulin Pumps)
Yes
Insured pays $20
per device.
•
Yes
Insured pays $100
per device.
Special Food Products and Enteral
Formulas
Special Food Products are limited to a
maximum benefit of $2,500 per Insured
per Calendar Year.
Yes
After CYD, SHL pays
90% of EME. See
maximum benefit.
After CYD, SHL pays
70% of EME. See
maximum benefit.
Temporomandibular Joint
Treatment
Maximum benefit is $2,500 per Insured
per Calendar Year and $4,000 per
lifetime.
Yes
After CYD, SHL pays
50% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
50% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
90% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
70% of EME.
Subject to the
maximum benefit.
Insulin Pump Supplies
Insulin Pumps
Mental Health Services
Inpatient Hospital Facility
Maximum benefit is thirty (30) days per
Insured per Calendar Year.
Outpatient Treatment
• Group Therapy
Limited to twenty (20) visits per
Insured per Calendar Year.
•
Individual, Family and Partial Care
Therapy**
Limited to twenty (20) visits per
Insured per Calendar Year.
Yes
Yes
Yes
Benefit maximum does not apply to
visits for medication management.
Form No. SHL-IndDAP-masBS-2005
Page 8
(NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3
Benefit Schedule
Covered Services and
Limitations
Prior
Auth
Required
Plan
Provider
Benefits(1)
Non-Plan
Provider
Benefits(1)
Mental Health Services (continued)
** Partial Care refers to a coordinated
outpatient program of treatment
that provides structured daytime,
evening and/or weekend services
for a minimum of four (4) hours per
session as an alternative to Inpatient
care.
Severe Mental Illness Services
Yes
After CYD, SHL
pays 90% of EME.
Subject to the
maximum benefit.
Outpatient Hospital Facility
Maximum benefit is forty (40) visits per
Insured per Calendar Year for all
outpatient services combined.
Yes
Insured pays $40
per visit. Subject to
the maximum
benefit.
Legal Documents
Inpatient Hospital Facility
Maximum benefit is forty (40) days per
Insured per Calendar Year.
After CYD, SHL pays
70% of EME.
Subject to the
maximum benefit.
Two (2) visits for partial or respite
care,or a combination thereof, may be
substituted for each (1) day of Inpatient
hospitalization not used by the Insured.
Benefit maximum does not apply to
visits for medication management.
Substance Abuse Services
Inpatient Rehabilitation
Maximum benefit is $9,000 per Insured
per Calendar Year.
Yes
Outpatient Rehabilitation*
• Group Therapy
• Individual, Family and Partial Care
Therapy**
Yes
After CYD, SHL pays
90% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
70% of EME.
Subject to the
maximum benefit.
*Rehabilitation counseling services for
all group, individual, family and partial
care therapy is limited to a maximum
benefit of $2,500 per Insured per
Calendar Year.
Form No. SHL-IndDAP-masBS-2005
Page 9
(NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3
Benefit Schedule
Prior
Auth
Required
Plan
Provider
Benefits(1)
Non-Plan
Provider
Benefits(1)
Inpatient Detoxification (treatment for
withdrawal)
Yes
After CYD, SHL pays
90% of EME.
Subject to the
maximum benefit.
After CYD, SHL pays
70% of EME.
Subject to the
maximum benefit.
Outpatient Detoxification
Yes
Covered Services and
Limitations
Substance Abuse Services
(continued)
Limited to a maximum benefit of
$1,500 per Insured per Calendar Year.
** Partial Care refers to a coordinated
outpatient program of treatment that
provides structured daytime, evening
and/or weekend services for a
minimum of four (4) hours per session
as an alternative to Inpatient care.
Please read the SHL Agreement of Coverage to determine the governing contractual provisions,
exclusions and limitations.
Please note in addition to specified surgical Copayment and/or Coinsurance amounts, Insured is also
responsible for all other applicable facility and professional Copayment and/or Coinsurance amounts as
outlined in the Attachment A Benefit Schedule.
Any and all amounts exceeding any stated maximum benefit amounts under the Plan do not accumulate
to the calculation of the Calendar Year Coinsurance Maximum.
(1)
If Medically Necessary Covered Services are provided without Prior Authorization, benefits are reduced
to 50% of what the Insured would have received with Prior Authorization.
Form No. SHL-IndDAP-masBS-2005
Page 10
(NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3
Distinct Advantage PPO
3-Tier Individual Prescription Drug Benefit Rider
PLAN PHARMACY
Tier I: Preferred Generic Covered Drugs
Insured pays:
$7.00 Preferred Generic Covered Drug Fee per Retail Plan Pharmacy Therapeutic Supply
$14.00 Preferred Generic Covered Drug Fee per Mail Order Plan Pharmacy Maintenance
Supply
Insured pays:
$35.00 Preferred Brand Name Covered Drug Fee without a Generic Covered Drug
equivalent per Retail Plan Pharmacy Therapeutic Supply
$70.00 Preferred Brand Name Covered Drug Fee per Mail Order Plan Pharmacy
Maintenance Supply
Tier III: Non-Preferred Generic or Brand Name Covered Drugs
Insured pays:
$55.00 Non-Preferred Generic or Brand Name Covered Drug Fee per Retail Plan
Pharmacy Therapeutic Supply
NON-PLAN PHARMACY
SHL pays 70% of EME for Covered Drugs less the applicable Generic, Brand Name or
Non-Preferred Drug Fee per Therapeutic Supply
Form No. SHL-IPPO-3TierSIO-2004
Page 1
(NV 2003\SHL IPPO) 41NVSHLRI_RXDAP
Legal Documents
Tier II: Preferred Brand Name Covered Drugs without a
Generic Covered Drug Equivalent
Prescription Drug Rider
This Prescription Drug Benefit Rider is issued in
consideration of: (a) your election of coverage
under this Rider, (b) your eligibility for the benefits
described in this Rider, and (c) payment of any
additional premium.
•
c) Tier III applies when:
This Prescription Drug Benefit Rider, when
attached to the Sierra Health and Life Insurance
Company, Inc. (“SHL”) Individual PPO Agreement
of Coverage (“AOC”) and Attachment A Benefit
Schedule amends your coverage to include
benefits for Covered Drugs. This coverage is
subject to the applicable terms, conditions,
limitations and exclusions contained in your SHL
AOC and herein.
SECTION 1.
Obtaining Covered
Drugs
Plan Pharmacy Benefit Payments
Benefits for Covered Drugs obtained at a Plan
Pharmacy are subject to the following provisions
as applicable:
a) Tier I applies when:
•
a Preferred Generic Covered Drug is
dispensed; and
•
any required Prior Authorization has been
obtained.
•
The Insured will pay the Preferred
Generic Drug Fee to the Plan Pharmacy
for each Therapeutic Supply.
b) Tier II applies when:
•
•
a Preferred Brand Name Covered Drug is
dispensed which has no Preferred
Generic Drug equivalent; and
any required Prior Authorization has been
obtained.
Form No. SHL-IPPO-3TierSIO-2004
a Non-Preferred Generic or Brand Name
Covered Drug is dispensed; and
•
any required Prior Authorization has been
obtained.
•
The Insured will pay the Non-Preferred
Drug Fee to the Plan Pharmacy for each
Therapeutic Supply.
•
A Generic Covered Drug will be dispensed
when available, subject to the prescribing
Provider’s “Dispense as written” requirements.
1.1
•
d) Mandatory Generic benefit provision
applies when:
Benefits for Covered Drugs are payable under the
terms of this Rider subject to the following
conditions:
•
The Insured will pay the Preferred Brand
Name Drug Fee to the Plan Pharmacy for
each Therapeutic Supply.
a Preferred Brand Name Covered Drug is
dispensed and a Generic Covered Drug
equivalent is available. The Insured will
pay the Tier I Covered Drug Fee plus the
difference between the EME of the
Generic Covered Drug and the EME of
the Brand Name Covered Drug to the
Plan Pharmacy for each Therapeutic
Supply.
e) When a Maintenance Drug is dispensed
through the Mail Order Plan Pharmacy, the
applicable Mail Order Plan Pharmacy benefit
tier will apply per Maintenance Supply.
1.2
Non-Plan Pharmacy Benefit Payments
When a Covered Drug is dispensed by a
Non-Plan Pharmacy, the Insured will pay to the
Non-Plan Pharmacy at the time the drug is
dispensed, the full cost of the Covered Drug
subject to the following:
a) In order that claims for Covered Drugs
obtained at a Non-Plan Pharmacy be eligible
for benefit payment, the Insured must
complete and submit a claim form with the
prescription label/receipt to SHL or its
designee.
b) Benefit payments are subject to the limitations
and exclusions set forth in the SHL AOC and
this Rider. All charges in excess of the EME
after SHL pays the Non-Plan Pharmacy
percentage shown less the applicable
Page 2
(NV 2003\SHL IPPO) 41NVSHLRI_RXDAP
Prescription Drug Rider
Preferred Generic, Brand Name or
Non-Preferred Covered Drug Fee will be paid
by the Insured.
without Prior Authorization, benefits are
reduced to 50% of what the Insured would
have received with Prior Authorization.
1. When a Preferred Generic or Brand Name
Covered Drug is dispensed by a Non-Plan
Pharmacy, the benefit payment will equal
the Non-Plan Pharmacy percentage less
the applicable Drug Fee. The Insured is
responsible for the amounts exceeding
SHL’s benefit payment.
2. When a Non-Preferred Covered Drug is
dispensed by a Non-Plan Pharmacy, the
benefit payment will equal the Non-Plan
Pharmacy percentage of EME less the
Non-Preferred Drug Fee. The Insured is
responsible for the amounts exceeding
SHL’s benefit payment.
a) Benefits for a Maintenance Supply of
Preferred Maintenance Drugs are available
when dispensed by an SHL Mail Order
Pharmacy for the applicable Mail Order Drug
Fee(s) as shown on page 1, and any
additional amounts subject to (a), (b) or (d) in
Section 1.1.
2.6 Benefits for Prior Authorized Medically
Necessary Compounds as defined herein
are payable according to the
Non-Preferred benefit tier.
2.7 Benefits for Non-Preferred Self-Injectable
and Orphan Covered Drugs as defined
herein are payable at 50% of EME.
b) Information on how to obtain Mail Order
Preferred Maintenance Drugs is provided in
the Mail Order Brochure provided after
enrollment in the Plan.
SECTION 3. Exclusions
SECTION 2. Limitations
2.1 Benefits for certain Medically Necessary
Covered Drugs may require Prior
Authorization from SHL including, but not
limited to some medical supplies,
outpatient immunosuppressive drugs, and
Self-Injectable and Orphan Covered
Drugs. If such Covered Drugs are provided
Page 3
No benefits are payable for the following drugs,
devices and supplies as well as for any
complications resulting from their use except
when prescribed in connection with the treatment
of Diabetes:
3.1 Any drug, supply or device which can be
purchased without a prescription, including
those prescribed;
(NV 2003\SHL IPPO) 41NVSHLRI_RXDAP
Legal Documents
2.5 Benefits for prescriptions for Mail Order
Maintenance Drugs submitted following
SHL’s receipt of notice of Individual’s
termination will be limited to the
appropriate Maintenance Supply as
defined herein, from the date such notice
of termination is received to the Effective
Date of termination of the Individual.
Mail Order Plan Pharmacy Benefit
Payments
Form No. SHL-IPPO-3TierSIO-2004
2.3 Benefits for certain Covered Drugs are
limited to a specific number of Therapeutic
Supplies during a Dispensing Period as
defined herein. If the applicable number of
Therapeutic Supplies is exceeded prior to
the expiration of the Dispensing Period, no
benefits are payable until the
commencement of any following
Dispensing Period.
2.4 A Pharmacy may refuse to fill a
prescription order or refill when in the
professional judgment of the pharmacist
the prescription should not be filled.
3. No benefits are payable if the EME of the
Covered Drug is less than the applicable
Covered Drug Fee.
1.3
2.2 Mail Order benefits only apply to
Maintenance Drugs as defined herein.
Prescription Drug Rider
3.2 Drugs which are available without charge
under local, state, or federal programs,
including Workers’ Compensation
programs, or approved clinical trial or
study;
3.14 Prescriptions for Covered Drugs that
exceed the applicable number of
Therapeutic Supplies in a given
Dispensing Period as determined by SHL;
3.15 Any drug that has been approved by the
FDA for less than nine (9) months unless
Prior Authorized by SHL;
3.3 Devices of any type, including those
prescribed by a licensed Provider, except
for prescription contraceptive devices;
3.16 Drugs and medicines approved by the FDA
for experimental or investigational use
except when prescribed for the treatment
of cancer or chronic fatigue syndrome
under a clinical trial or study approved by
the Plan;
3.4 Anorexic agents (weight reducing drugs),
drugs prescribed for cosmetic purposes,
hair growth, infertility drugs, nicotine
suppressants, or erectile dysfunction
drugs;
3.5 Hypodermic needles, syringes, or similar
devices used for any purpose other than
the administration of Self-Injectable
Covered Drugs;
3.17 Compounds that are determined not to be
Medically Necessary or are not Prior
Authorized by SHL; and
3.18 Any class of Prescription Drugs for which
an over-the-counter therapeutic equivalent
is available.
3.6 Except as otherwise specifically provided,
Prescription Drugs related to medical
services which are not covered under the
SHL AOC;
SECTION 4. Glossary
3.7 Drugs for which prescriptions are written by
a licensed Provider for use by the Provider
or by his or her immediate family members;
4.1 “Brand Name Drug” is a Prescription
Drug which is marketed under or protected
by:
• a registered trademark; or
3.8 Prescription Drugs dispensed prior to the
Insured’s Effective Date of coverage or
after Insured’s termination date of
coverage under the Plan;
• a registered trade name; or
• a registered patent.
3.9 Over-the-counter drugs, multivitamins and
nutritional supplements;
4.2 “Compound” means to form or create a
Medically Necessary customized
composite product by combining two (2) or
more different ingredients according to a
Physician’s specifications to meet an
individual patient’s need.
3.10 Any Prescription Drug for which the actual
charge to the Insured is less than the
amount due under this Rider;
3.11 Any refill in excess of the amount specified
by the prescription order;
4.3 “Coinsurance” means the percentage of
the charges billed or the percentage of
Eligible Medical Expenses that an Insured
must pay to the Non-Plan Pharmacy for
Covered Drugs.
3.12 Any refill dispensed; 1) more than one (1)
year from the date of the latest prescription
order or as permitted by applicable law of
the jurisdiction in which the drug is
dispensed; or 2) as a result of a lost or
stolen prescription;
4.4 “Covered Drug” is a Brand Name or
Generic Prescription Drug which:
• can only be obtained with a prescription;
3.13 Medical supplies unless listed in the
Preferred list or Prior Authorized by SHL;
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(NV 2003\SHL IPPO) 41NVSHLRI_RXDAP
Prescription Drug Rider
• has been approved by the Food and
Drug Administration (“FDA”) for general
marketing, subject to 3.15 above;
conditions as determined by SHL to
include but not be limited to the following:
Diabetes, Arthritis, Heart Disease and High
Blood Pressure. For purposes of this Rider,
Maintenance Drugs do not include
Self-Injectable or Orphan Covered Drugs
other than those for the treatment of
Diabetes.
• is dispensed by a licensed pharmacist;
• is prescribed by a licensed Provider;
• is a Prescription Drug that does not
have an over-the-counter therapeutic
equivalent available; and
• is not specifically excluded herein.
4.5 “Dispensing Period” as established by
SHL means 1) a predetermined period of
time; or 2) a period of time up to a
predetermined age attained by the Insured
that a specific Covered Drug is
recommended by the FDA to be an
appropriate course of treatment when
prescribed in connection with a particular
condition.
4.7 “Eligible Medical Expense (EME)” for
purposes of this Rider, means the Plan
Pharmacy contracted cost of the Covered
Drug to SHL but not more than the actual
charge to the Insured.
4.8 “Generic Drug” is an FDA-approved
Prescription Drug which does not meet the
definition of a Brand Name Drug as defined
herein.
4.9 “Mail Order Plan Pharmacy” is a duly
licensed pharmacy that has an
independent contractor agreement with
SHL to provide certain Preferred
Maintenance Drugs to Insureds by mail.
4.13 “Non-Preferred” for purposes of this
Rider, means those Covered Drugs not
included on the Preferred list.
4.14 “Orphan Drugs” means a Prescription
Drug for the treatment or prevention of a
rare disease or condition as determined by
the FDA. A rare disease is one that affects
less than 200,000 people in the U.S. or
one that affects more than 200,000 people
but for which there is no reasonable
expectation that the cost of developing the
drug and making it available will be
recovered from sales of that drug in the
U.S.
4.15 “Plan Pharmacy” is a duly licensed
pharmacy that has an independent
contractor agreement with SHL to provide
Covered Drugs to Insureds. Unless
otherwise specified as Mail Order Plan
Pharmacy herein, Plan Pharmacy services
are retail services only and do not include
Mail Order services.
4.16 “Preferred” or “Preferred Drug List
(PDL)” means a list of FDA approved
Generic and Brand Name Prescription
Drugs established, maintained and
recommended for use by SHL.
4.10 “Maintenance Drug” is a Preferred
Covered Drug prescribed to treat certain
chronic or life-threatening long-term
Form No. SHL-IPPO-3TierSIO-2004
4.12 “Non-Plan Pharmacy” is a duly licensed
pharmacy that does not have an
independent contractor agreement with
SHL to provide Covered Drugs to Insureds.
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(NV 2003\SHL IPPO) 41NVSHLRI_RXDAP
Legal Documents
4.6 “Drug Fee” is the predetermined amount
shown in this Rider that the Insured is
responsible for paying directly to the Plan
Pharmacy for each Therapeutic Supply of
a Covered Drug at the time the prescription
is dispensed. Drug Fees or any amounts
paid in addition to the Drug Fee do not
apply to the Coinsurance and/or
Copayment Maximum set forth in the
Attachment A Benefit Schedule, if any.
4.11 “Maintenance Supply” is the quantity, as
determined by SHL, of a Preferred
Maintenance Drug for which Mail Order
benefits are available for a specified
number of Drug Fees or Coinsurance
amount, and may be less than but shall not
exceed a 90-day supply.
Prescription Drug Rider
4.17 “Prescription Drug” is any drug required
by federal law or regulation to be
dispensed upon written prescription
including finished dosage forms and active
ingredients subject to the Federal Food,
Drug and Cosmetic Act.
The Plan’s PDL is subject to change during the
year based on P&T Committee decisions and
recommendations. Questions about the Plan’s
PDL should be directed to the Member Services
Department at (702) 242-7700 or 1-800-888-2264
(Fax: (702) 240-6281) from 8:00 a.m. – 5:00 p.m.
Pacific Time.
4.18 “Self-Injectable” Covered Drug is an
injectable Covered Drug, which is to be
administered subcutaneously or
intramuscularly, which does not require
administration by a licensed Practitioner.
Injectable Covered Drugs meeting this
definition are considered Self-Injectable
Covered Drugs even when administered
by a licensed Practitioner or someone
other than the Insured.
4.19 “Therapeutic Supply” is the maximum
quantity of a Covered Drug for which
benefits are available for a single
applicable Drug Fee or the applicable
Coinsurance amount and may be less than
but shall not exceed a 30-day supply.
Important Notice regarding the
Preferred Drug List (PDL)
The PDL is developed and maintained by the
Plan’s Pharmacy and Therapeutics (P&T)
Committee, which is comprised of Primary Care
and Specialty Physicians, pharmacists and other
healthcare Providers. The Committee meets at
least annually and as needed throughout the year
to evaluate the PDL and review new and existing
categories of drugs. Drugs and drug classes are
evaluated based upon FDA-approved indications,
effectiveness, adverse effect profile, patient
monitoring requirements, patient dosage and
administration guidelines, impact on total
healthcare costs, and comparison to other drugs
on the PDL. Cost becomes a determining factor
when minimal or no differences exist when
comparing effectiveness with other drug specific
parameters.
The Committee uses medical and clinical
literature, relevant patient utilization and
experience, current therapeutic guidelines,
economic data, and Provider recommendations in
its decision-making process.
Form No. SHL-IPPO-3TierSIO-2004
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(NV 2003\SHL IPPO) 41NVSHLRI_RXDAP