Covered Benefits

(1) Plan Members are eligible to receive Covered Benefits subject to their compliance with the payment specifications under 651 CMR 15.07. (2) Covered Benefits include Prescription Drugs that are on the Plan Formulary, are dispensed by a retail pharmacy (including mail service) and can be self-administered. Covered Benefits do not include any Prescription Drugs that are administered in an inpatient setting. For Members enrolled in Medicare, Covered Benefits are only those products that are covered by the Medicare Part D Plan or Creditable Coverage Plan in which the Member is enrolled and benzodiazepines. (3) Access to Covered Benefits shall not commence until the Effective Date of Coverage. No Prescription Drug procured by a Member prior to the Effective Date of Coverage shall be considered a Covered Benefit. (4) Covered Benefits include items not on the Plan Formulary only when approved for coverage pursuant to Review procedures set forth in 651 CMR 15.15. (5) To ensure appropriate use of Covered Benefits, the Plan may require Prior Authorization and may use benefit management tools, including quantity limitations for certain Prescription Drugs.