§ 135-45.6. Benefits not subject to deductible or coinsurance. - North Carolina Statutes

§ 135‑45.6.  Benefitsnot subject to deductible or coinsurance.

(a)        Immunizations. – ThePlan will pay one hundred percent (100%) of allowable medical charges forimmunizations for the prevention of contagious diseases as generally acceptedmedical practices would dictate when directed by a credentialed provider asdetermined by the claims processor.

(b)        Prescription Drugs.– The Plan's allowable charges for prescription legend drugs to be used outsideof a hospital or skilled nursing facility shall be as determined by the Plan'sExecutive Administrator and Board of Trustees, which determinations are notsubject to appeal under Article 3 of Chapter 150B of the General Statutes. Co‑paymentsand other allowable charges or coverage for prescription drugs shall be asfollows:

(1)        The Plan will payallowable charges for each outpatient prescription drug less a copayment to bepaid by each covered individual equal to the following amounts: pharmacycharges up to ten dollars ($10.00) for each generic prescription, thirty‑fivedollars ($35.00) for each preferred branded prescription without a genericequivalent, and fifty‑five dollars ($55.00) for each nonpreferred brandedprescription. For each branded prescription drug with a generic equivalentdrug, the member shall pay the generic co‑payment plus the differencebetween the Plan's gross allowed cost for the generic prescription and thePlan's cost for the branded prescription drug.

(2)        The Plan shallprovide coverage of nonacute specialty medications, excluding cancermedications, under the Plan's pharmacy benefit through a specialty pharmacyvendor under contract with the Plan. The Plan may transfer coverage ofspecified specialty disease medications covered under the Plan's medicalbenefit to the contracted specialty pharmacy vendor. Specialty medications arecovered biotech medications and other medications designated and classified bythe Plan as specialty medications that are significantly more expensive thanalternative drugs or therapies. Medications classified by the Plan as specialtymedications shall meet all of the following conditions:

a.         Have unique uses forthe treatment of complex diseases.

b.         Require specialdosing or administration.

c.         Require specialhandling.

d.         Are typicallyprescribed by a specialist provider.

e.         Exceed four hundreddollars ($400.00) cost to the Plan per prescription.

ThePlan shall impose a co‑payment in the amount of twenty‑five percent(25%) of the Plan's gross allowed cost of the specialty drug not to exceed onehundred dollars ($100.00) per prescription per 30‑day supply.

(3)        The Plan may excludecoverage of drugs that have therapeutic equivalents, as defined by the U.S.Food and Drug Administration, that are available over the counter. Beforeexcluding coverage under this subdivision, the Plan shall consult with thePlan's Pharmacy and Therapeutics Committee.

(4)        A Plan member shallpay the lesser of copayments provided under this subsection or a pharmacy'scash price to the general public for a particular prescription. The Plan'spharmacy benefit manager may remove from the pharmacy network any pharmacy thatcharges an amount in violation of this subdivision. Prescriptions shall be forno more than a 30‑day supply for the purposes of the copayments paid byeach covered individual. By accepting the copayments and any remainingallowable charges provided by this subsection, pharmacies shall not balancebill an individual covered by the Plan. A prescription legend drug is definedas an article the label of which, under the Federal Food, Drug, and CosmeticAct, is required to bear the legend: "Caution: Federal Law ProhibitsDispensing Without Prescription." Such articles may not be sold to orpurchased by the public without a prescription order. Benefits are provided forinsulin even though a prescription is not required. The Plan may adoptutilization management procedures for certain drugs, but in no event shall thePlan provide coverage for sexual dysfunction or hair growth drugs ornonmedically necessary drugs used for cosmetic purposes. Any formulary used bythe Plan's Executive Administrator and pharmacy benefit manager shall be anopen formulary. Plan members shall not be assessed more than two thousand fivehundred dollars ($2,500) per person per fiscal year in copayments required bythis subsection. The Plan's Pharmacy Benefit Manager, or any pharmacy or vendorparticipating in the Plan shall charge the Plan for any prescription legenddrug dispensed under the Plan's pharmacy benefit based upon the originalNational Drug Code (NDC) as established by the manufacturer of the prescriptionlegend drug and published by the United States Food and Drug Administration.  (1981 (Reg. Sess., 1982), c.1398, s. 6; 1983, c. 922, s. 7; 1985, c. 192, ss. 5, 9, 12; c. 732, ss. 16‑18;1985 (Reg. Sess., 1986), c. 1020, ss. 10, 20; 1987, c. 857, s. 14; 1991, c.427, ss. 13, 20; 1995, c. 507, s. 7.24(a); 1999‑237, s. 28.28(b); 2000‑141,s. 1; 2000‑184, s. 2; 2001‑253, ss. 1(d), 1(e); 2003‑186, s.5(a); 2005‑276, s. 29.31(a); 2006‑249, s. 2(a); 2007‑323, s.28.22A(a); 2008‑168, ss. 1(a), 3(a), (j); 2009‑16, s. 2(c); 2009‑571,s. 3(e).)