Coverage Policies and Guidelines. HPNs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on HPN’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including, but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding covered persons as a general population. Whether a particular Prescription Drug is appropriate for an individual covered person is a determination that is made by the covered person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about HPN’s PDL should be directed to the Member Services Department at 000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available is available at xxxx://xxxxxxxxxxxxxxxxxx.xxx/~/media/Files/HPN/pdf/Forms/OptumRx- Reimbursement.ashx?la=en. Coupons HPN may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the Member’s annual CYD and/or Out of Pocket Maximum or to reduce the Member’s Copayments and/or Coinsurance. Costs defrayed for the Member as Agreement of Coverage a result of pharmaceutical coupons are not Eligible Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxx.xxx. Rebates and Other Payments HPN may receive rebates for certain drugs included on the Prescripti...
Coverage Policies and Guidelines. SHLs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHL’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician.
Coverage Policies and Guidelines. SHLs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHL’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician.
