Page images
PDF
EPUB
[graphic][merged small][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][ocr errors][ocr errors][ocr errors][ocr errors][subsumed][ocr errors][subsumed][ocr errors][ocr errors][subsumed][ocr errors][subsumed][ocr errors][subsumed][subsumed][subsumed][ocr errors][ocr errors][ocr errors][ocr errors][subsumed][subsumed][subsumed][subsumed][ocr errors][subsumed][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][subsumed][ocr errors][ocr errors]

membership card

A. Is the card currently valid?

Check "EXPIRATION DATE" (see illustration, Item 1).

8. Is the patient eligible"

Check "TYPE OF CONTRACT" under Series code (Item 2).

• If this says "IND", only the person named under "NAME OF SUBSCRIBER" (Item 3)
is eligible.

• If this says "FAM", the named subscriber, his wife, and children up to the age specified
under "AGE OF DEPENDENT CHILD" (Item

are eligible.

C. If prescription is for a contraceptive drug, does subscriber have special coverage?
Check under "SPECIAL BENEFITS" (Item 6).

• If "YES" appears, contraceptive drugs are covered.

• If "NO", there is no coverage for contraceptive drugs, regardless of the purpose for
which the drug is prescribed.

[merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][ocr errors][merged small][ocr errors][ocr errors][merged small]

MISSOURI WELFARE

Drugs covered: Those listed in drug formulary.

Drugs not covered: Any drug not appearing in formulary.

Generics: Use lowest cost in stock.

Maximum quantities: Cannot exceed a 30-day supply.

Refills: Not to exceed six refills or no longer than 6 months, whichever comes

first.

Number Rx's per claim form: New claim form for each patient.

ID card: Issued monthly.

Dependents covered: Those listed on ID card.

Co-pay: None.

Professional fee: $1 professional fee plus 10 cents for container.1
Acquisition cost: Use cost stated in formulary.2

Insulin: No professional fee or container charge. Use formulary price.
State tax: None.

Imprinter: None.

Drug identification on claim: Drug code listed in formulary.

Claim distribution: Prepare in duplicate and send both to general office.

When forwarded: Forward in charge account transactions envelope at the end of each week.

Reorder claim forms from: Division of Welfare, State Office Building, Jefferson City, Mo.

Total price (formulary price plus fee plus container charge) cannot exceed price charged to “regular customer'

2 Represents cost for generics. The State will not pay more than this amount, plus fee and container charge, even if trade name product is used.

[graphic][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][ocr errors][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed]
[blocks in formation]

Drugs covered: Legend drugs; compounds w/a legend; insulin.

Drugs not covered: Contraceptives, whether prescribed for contraception or not; Rx's whose usual retail is $2 and under.

Generics: When written for, use lowest cost drug in stock.

Maximum quantities: 34-day supply, except for 100's of thyroid and nitroglycerin.

Refills: Up to 1 year.

Number Rx's per claim form: three per subscriber.

ID card: Plastic.

Dependents covered: Stated on ID card.

Co-pay: $2.

Professional fee: $2.

Acquisition cost: Rolodex.

Insulin: See footnote 1; if taxable.2

State tax: Not charged to customer. Tax is included in professional fee.
Imprinter: None.

Drug identification on claim: Write drug name.

Claim distribution: All copies to G.O. accounting.

When forwarded: End of each week with sales and cash report.

Reorder claim forms from: Metropolitan Life Insurance, 1 Madison Avenue, New York, NY 10010, Prescription Drug Plan.

1 On insulin, acquisition cost plus professional fee or "usual charge," whichever is lower, less co-pay.

2 In all States with tax on insulin, tax is added to acquisition cost when "usual charge" is used. If professional fee is used, tax is included in fee.

« PreviousContinue »