Do the requirements applicable to group health plans apply to prescription drug benefit programs offered as a stand-alone plan or as part of a group health plan?
Yes, in both cases. Prescription drug benefits would, like dental benefits, constitute medical care within the meaning of Section 733(a)(2). See question A-6. Accordingly, the provision of prescription drug benefits, either as a stand-alone plan, or as part of a group health plan, would be subject to the requirements of the regulation applicable to group health plans. Whether, and under what circumstances, specific practices permitted under the plan, such as the submission of a prescription to a pharmacy or pharmacist, will constitute a claim for benefits governed by the claims procedure rules will depend on the terms of the plan.
Yes, in both cases. Prescription drug benefits would, like dental benefits, constitute ‘medical care’ within the meaning of Section 733(a)(2). Accordingly, the provision of prescription drug benefits, either as a stand-alone plan, or as part of a group health plan, would be subject to the requirements of the regulation applicable to group health plans. Whether, and under what circumstances, specific practices permitted under the plan, such as the submission of a prescription to a pharmacy or pharmacist, will constitute a claim for benefit governed by the claims procedure rules will depend on the terms of the plan.” Participants are accustomed to the ease in which they obtain prescriptions under the point of service (“POS”) arrangement, under most plans. It should not be a plan’s intent to revise this arrangement. However, a plan should carefully describe this process in the plan as a convenience to the plan participants, but not an actual claim for benefits. An actual claim for benefit
Yes, in both cases. Prescription drug benefits would, like dental benefits, constitute medical care within the meaning of Section 733(a)(2). See Q-A6. Accordingly, the provision of prescription drug benefits, either as a stand-alone plan, or as part of a group health plan, would be subject to the requirements of the regulation applicable to group health plans. Whether, and under what circumstances, specific practices permitted under the plan, such as the submission of a prescription to a pharmacy or pharmacist, will constitute a claim for benefits governed by the claims procedure rules will depend on the terms of the plan.
Related Questions
- Do the requirements applicable to group health plans apply to prescription drug benefit programs offered as a stand-alone plan or as part of a group health plan?
- Do the requirements applicable to group health plans apply to dental benefits offered as a stand-alone plan or as part of a group health plan?
- Do the requirements applicable to group health plans apply to dental benefits offered as a stand-alone plan or as part of a group heath plan?
