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) • If this says "FAM", the named subscriber, his wife, and children up to the age specified are eligible. C. If prescription is for a contraceptive drug, does subscriber have special coverage? • If "YES" appears, contraceptive drugs are covered. • If "NO", there is no coverage for contraceptive drugs, regardless of the purpose for 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 Insulin: No professional fee or container charge. Use formulary price. 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. 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. 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. |