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Pharmacy Policies - Terms and Conditions

About our pharmacy policies

The Blue Cross and Blue Shield of Oklahoma and BlueLincs HMO medical affairs teams – which include board-certified physicians, licensed pharmacists and registered nurses – have developed pharmacy policies to help evaluate decisions regarding benefit coverage. The policies are based upon generally accepted standards of medical practice, current evidence-based research from nationally recognized medical authorities, pharmacy manufacturer guidelines, current published medical literature and peer-reviewed publications, as well as input from local medical specialists. The policies are reviewed and updated on an ongoing basis as new research and recommendations are available. Blue Cross and Blue Shield of Oklahoma and BlueLincs HMO reserve the right to update the policies without notice, and if there has been a recent change in a policy, it may not yet be included on this Web site.

Refer to plan documents for benefits

Blue Cross and Blue Shield of Oklahoma and BlueLincs HMO offer several distinct benefit plans, including fully insured PPO and HMO plans. Blue Cross and Blue Shield also administers various self-funded employer-sponsored health plans and plans for federal employees. Always refer to the member’s official plan documents – including (but not limited to) summary plan descriptions, member contracts and benefit booklets – for specific questions regarding benefit coverage. The plan documents will describe what services are covered benefits and which are excluded, and to what extent there are dollar caps or other limitations. In the event of a conflict between a pharmacy policy and any official plan document, the plan document will govern.

Medical necessity

Covered benefits are available only for medical services or treatments that are medically necessary, unless otherwise specified in the member’s benefit plan documents. Medically necessary services are defined as services or supplies provided by a physician or other health care provider to identify and treat a member's illness or injury, which, as determined by the payor, are consistent with the symptoms, diagnosis and treatment of the member's condition; in accordance with the standards of good medical practice; not solely for the convenience of the member, member's family, physician or other health care provider; and furnished in the least intensive type of medical care setting required by the member's condition. The determination by Blue Cross and Blue Shield of Oklahoma or BlueLincs HMO regarding medical necessity does not represent that the service is a covered benefit. At the time a claim for benefits is submitted, a determination will be made based upon limitations, exclusions and benefit descriptions in the member’s plan documents and the member’s eligibility at the time. The fact that a physician or other health care provider prescribes or orders a medical service or treatment does not ensure that the service or treatment is medically necessary, nor does it ensure that it is a covered benefit.

No treatment recommendations implied

These pharmacy policies do not constitute medical advice or guarantee the results or outcomes of specific medical services or treatments. All decisions regarding a member’s treatment regimen or plan of care are made between the member and his or her physician or other health care provider.

If you understand and agree with the terms and conditions stated above, please click "I Agree."


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