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"quantity vs. time" limits program equals changes for
your drug refills Q. When I went to the pharmacy to get my pain medication prescription refilled, the pharmacist would not fill it. She told me a refill would exceed the clinically appropriate amount of medication that I should take in a 30-day period. She also said that I must get approval from my doctor before I could get a refill. Why? A. In the last issue of Benefits Pulse, we told readers about a new HMO Blue program called Quantity vs. Time. This program monitors and prevents improper use of certain prescriptions. QVT limits the amount of prescription medicine dispensed in two categories: proton pump inhibitors and pain management. For example, PPIs like Prevacid, Prilosec, Nexium and Oxycontin should be used for only 180 days. Then, you should be re-evaluated by your doctor. If you want a new prescription, you must ask your doctor to approve additional refills. If your doctor agrees, she must call Pharmacy Programs, (972) 766-2725; send a fax to (800) 986-9980; or e-mail through the Web site www.clinical_pharmacy@bcbstx.com. Q. My wife’s employer told her she will be laid off from her job in 30 days. She has a medical condition that requires ongoing treatment and medications. We can’t afford the cost of her company’s medical coverage under COBRA. If I can add her and our children to my medical plan, will her treatment and medications be covered? And what kind of documentation do I need? A. Yes.
This is a family status change. If the medical plan covers her condition and medications, they will be covered immediately. You must provide a completed medical/dental change form, a life insurance change form, a certified copy of your marriage license and documentation that they have lost coverage, such as a certificate of creditable coverage or a letter from her employer or insurance company. If you have an informal marriage, you must provide a declaration and registration of an informal marriage certificate from your county clerk. Birth certificates are required for eligible dependent children. You may add only family members who were covered under her plans.
Q. If I die before my spouse and children, can they keep my medical and dental coverage? A. Your covered spouse may keep your medical/dental coverage until she remarries or is covered under another group health plan. Your spouse pays the same premium as an active employee. Your covered children are eligible until they reach age 25; or after age 25 if they are disabled and proof of the disability is given to the medical plan provider. To retain coverage, your spouse must pay the premiums.
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