Substance Use Disorder Treatment and
Breast Cancer Imaging Cost-Sharing Rider
{Drafting Note: Use this rider for plans that provide large group coverage that does not include prescription drug coverage.}
This rider amends Your [Certificate; Contract; Policy] to provide benefits for the Covered Services described below.
I. Coverage of Medications for the Detoxification or Maintenance Treatment of a Substance Use Disorder
A. Covered Medications for Substance Use Disorder Treatment.
We Cover Medically Necessary medications for the detoxification or maintenance treatment of substance use disorder (“SUD Medications”) that are:
· FDA approved for the treatment of substance use disorder; and
· Dispensed by a licensed pharmacy.
[You may request a copy of Our Formulary.] [Our Formulary is also available on Our website [at XXX].] You may inquire if a specific drug is Covered under this rider by contacting us at [XXX; the number on Your ID card].
B. Refills.
We Cover Refills of SUD Medications only when dispensed at a retail [or] [mail order] pharmacy [and only after ¾ of the original SUD Medication has been used]. Benefits for Refills will not be provided beyond one (1) year from the original prescription date.
{Drafting Note: The bracketed language above is optional.}
C. Benefit and Payment Information.
1. Cost-Sharing Expenses. Your Cost-Sharing for SUD Medications is as follows:
Medications for the Detoxification or Maintenance Treatment of a Substance Use Disorder / [Preferred Provider Member Responsibility for Cost-Sharing] / Participating Provider Member Responsibility for Cost-Sharing / Non-Participating Provider Member Responsibility for Cost-SharingRetail Pharmacy
30-day supply
[Tier 1
Tier 2
Tier 3] / [$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible] / [$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible] / [$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[Non-Participating Provider services are not Covered and You pay the full cost]
[Mail Order Pharmacy]
[Up to a [90]-day supply
Tier 1
Tier 2
Tier 3] / [$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible] / [$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible] / [$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[$ Copayment]
[% Coinsurance]
[[after; not subject to] Deductible]
[Non-Participating Provider services are not Covered and You pay the full cost]
[You have a one (1) tier plan design, which means that You will have the same out-of-pocket expenses for all SUD Medications.]
[You have a two (2) tier plan design, which means that You will have lower out-of-pocket expenses for [tier 1 drugs; Generic Drugs] and higher out-of-pocket expenses for [tier 2 drugs; Brand-Name Drugs].]
[You have a three (3) tier plan design, which means that Your out-of-pocket expenses will generally be lowest for SUD Medications on tier 1 and highest for SUD Medications on tier 3. Your out-of-pocket expense for SUD Medications on tier 2 will generally be more than for tier 1 but less than tier 3.]
{Drafting Note: Plans may include one, two or three tiers.}
[An additional charge may apply when a SUD Medication on a higher tier is dispensed at Your [or Your Provider’s] request, when a chemically equivalent SUD Medication is available on a lower tier [unless We approve coverage at the higher tier]. You will have to pay the difference between the cost of the SUD Medication on the higher tier and the cost of the SUD Medication on the lower tier. The cost difference must be paid in addition to the lower tier Copayment or Coinsurance. [However, the cost difference will apply toward Your [In-Network] Out-of-Pocket Limit if the lower tier SUD Medication is not medically appropriate for You.]]
{Drafting Note: The paragraph above is optional. If the paragraph is used, plans should either: 1) cover the higher tier drug by using the bracketed language beginning with “unless We approve…”; or 2) apply the cost difference towards the out-of-pocket limit by inserting the last bracketed sentence.}
You are responsible for paying the full cost (the amount the pharmacy charges You) for any non-Covered SUD Medication, and Our contracted rates (Our Medication Cost) will not be available to You.
2. Participating Pharmacies. For SUD Medications purchased at a Participating Pharmacy, You are responsible for paying the lower of:
· The applicable Cost-Sharing; or
· The Participating Pharmacy’s Usual and Customary Charge (which
includes a dispensing fee and sales tax) for the SUD Medication.
(Your Cost-Sharing will never exceed the Usual and Customary Charge of the SUD Medication.)
[In the event that Our Participating Pharmacies are unable to provide the Covered SUD Medication, and cannot order the SUD Medication within a reasonable time, You may, with Our prior [written] approval, go to a Non-Participating Pharmacy that is able to provide the SUD Medication. We will pay You the SUD Medication Cost for such approved SUD Medication less Your required in-network Cost-Sharing [upon receipt of a complete claim form]. Contact Us at [XXX; the number on Your ID card] [or visit our website [at XXX]] to request approval.]
{Drafting Note: The bracketed paragraph above is required for HMO and EPO coverage and optional for PPO coverage. Bracketed language within the paragraph (for example, “written”) is optional.}
3. Non-Participating Pharmacies. [We will not pay for any SUD Medications that You purchase at a Non-Participating Pharmacy other than as described above.] [If You purchase a SUD Medication from a Non-Participating Pharmacy, You must pay for the SUD Medication at the time it is dispensed and then file a claim for reimbursement with Us. We will not reimburse You for the difference between what You pay the Non-Participating Pharmacy and Our price for the SUD Medication. In most cases, You will pay more if You purchase SUD Medications from a Non-Participating Pharmacy.]
{Drafting Note: Choose the appropriate bracketed provision depending on whether out-of-network coverage is provided.}
[4.] [Mail Order. [Certain SUD Medications may be ordered through Our mail order pharmacy. You are responsible for paying the lower of:
· The applicable Cost-Sharing; or
· The Medication Cost for that SUD Medication.
(Your Cost-Sharing will never exceed the Usual and Customary Charge of the SUD Medication.)
To maximize Your benefit, ask Your Provider to write Your Prescription Order or Refill for a 90-day supply, with Refills when appropriate (not a 30-day supply with three (3) Refills). You [will; may] be charged the mail order Cost-Sharing for any Prescription Orders or Refills sent to the mail order pharmacy regardless of the number of days supply written on the Prescription Order or Refill.
SUD Medications purchased through mail order will be delivered directly to Your home or office.
We will provide benefits that apply to drugs dispensed by a mail order pharmacy to drugs that are purchased from a retail pharmacy when that retail pharmacy has a participation agreement with [Us] [and; or] [Our vendor] in which it agrees to be bound by the same terms and conditions as a participating mail order pharmacy.
You or Your Provider may obtain a copy of the list of SUD Medications available through mail order by visiting Our website [at XXX] or by calling [XXX; the number on Your ID card].]
{Drafting Note: Mail order drug coverage is optional. If mail order drug coverage is provided, the above language must be used.}
[5.] Tier Status. The tier status of a SUD Medication may change periodically. Changes will generally be quarterly, but no more than six (6) times per [calendar year; Plan Year], based on Our periodic tiering decisions. These changes may occur without prior notice to You. However, if You have a prescription for a drug that is being moved to a higher tier (other than a Brand-Name Drug that becomes available as a Generic Drug as described below) We will notify You. When such changes occur, Your out-of-pocket expense may change. You may access the most up to date tier status on Our website [at XXX] or by calling [XXX; the number on Your ID card].
[6.] When a Brand-Name Drug Becomes Available as a Generic Drug. When a Brand-Name Drug becomes available as a Generic Drug, the tier placement of the Brand-Name prescription Drug may change. If this happens, [You will pay the Cost-Sharing applicable to the tier to which the SUD Medication is assigned] [You no longer have benefits for that particular Brand-Name Drug. Please note, if You are taking a Brand-Name Drug that is being excluded due to a Generic Drug becoming available, You will receive advance written notice of the Brand-Name Drug exclusion. If coverage is denied, You are entitled to an Appeal as outlined in the Utilization Review and External Appeal sections of the [Certificate; Contract; Policy].]
{Drafting Note: Insert one of the bracketed provisions above as applicable.}
[7.] Supply Limits. We will pay for no more than a [30; 90]-day supply of a SUD Medication purchased at a retail pharmacy. You are responsible for [one (1) Cost-Sharing amount; up to three (3) Cost-Sharing amounts] for up to a [30; 90]-day supply. [However, for Maintenance Drugs We will pay for up to a 90-day supply of a drug purchased at a retail pharmacy. You are responsible for [one (1) Cost-Sharing amount; up to three (3) Cost-Sharing amounts; one (1) Cost-Sharing amount for prescription drugs on tier 1 and three (3) Cost-Sharing amounts for SUD Medications on tier 2 and tier 3] for a 90-day supply at a retail pharmacy.]
{Drafting Note: Include the bracketed language if the Plan covers a 90-day supply of maintenance drugs. Plans may insert one of the cost-sharing options from the brackets above.}
[Some SUD Medications may be subject to quantity limits based on criteria that We have developed, subject to Our periodic review and modification. The limit may restrict the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month’s supply. You can determine whether a SUD Medication has been assigned a maximum quantity level for dispensing by accessing Our website [at XXX] or by calling [XXX; the number on Your ID card]. If We deny a request to Cover an amount that exceeds Our quantity level, You are entitled to an Appeal pursuant to the Utilization Review and External Appeal sections of the [Certificate; Contract; Policy].]
{Drafting Note: The language above is optional.}
[8.] Emergency Supply of Prescription Drugs for Substance Use Disorder Treatment. If You have an Emergency Condition, You may immediately access, without Preauthorization, a five (5) day emergency supply of a prescribed SUD Medication, including a prescription drug to manage opioid withdrawal and/or stabilization and for opioid overdose reversal. If You have a Copayment, it will be [the same Copayment that would apply to a 30-day supply of the SUD Medication. If You receive an additional supply of the SUD Medication within the 30-day period in which You received the emergency supply, You will not be responsible for an additional Copayment for the remaining 30-day supply of that SUD Medication.] [prorated. If You receive an additional supply of the SUD Medication within the 30-day period in which You received the emergency supply, Your Copayment for the remainder of the 30-day supply will also be prorated. In no event will the prorated Copayment(s) total more than Your Copayment for a 30-day supply.]
{Drafting Note: Insert one of the bracketed provisions describing the copayments charged for the limited supply.}
In this paragraph, “Emergency Condition” means a substance use disorder condition that manifests itself by acute symptoms of sufficient severity, including severe pain or the expectation of severe pain, such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:
· Placing the health of the person afflicted with such condition or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy;
· Serious impairment to such person’s bodily functions;
· Serious dysfunction of any bodily organ or part of such person; or
· Serious disfigurement of such person.
D. [Medical Management. This rider includes certain features to determine when SUD Medications should be Covered, which are described below. As part of these features, Your prescribing Provider may be asked to give more details before We can decide if the SUD Medication is Medically Necessary, other than for an emergency supply of prescription drugs for substance use disorder treatment.
{Drafting Note: The preauthorization paragraphs below are optional. If the preauthorization language is included, use one of the bracketed provisions in the second sentence of the first paragraph that explains how preauthorization works. Please note that the obligation to request preauthorization for prescription drugs is on the provider. In addition, include the first sentence in the second paragraph that explains how the member can determine which drugs require preauthorization.}
[1.] [Preauthorization. Preauthorization may be needed for certain SUD Medications to make sure proper use and guidelines for SUD Medication coverage are followed. When appropriate, [We will contact Your Provider to determine if Preauthorization should be given] [ask Your Provider to complete a Preauthorization form] [Your Provider will be responsible for obtaining Preauthorization for the SUD Medication]. [Should You choose to purchase the SUD Medication without obtaining Preauthorization, You must pay for the cost of the entire SUD Medication and submit a claim to Us for reimbursement.]