Current Plan Benefit Design - General Sample Clauses

Current Plan Benefit Design - General. The BHS Program is the payer of last resort for medically necessary medications in the treatment of mental illness. The formulary is posted on the BHS Program website at: xxx.xxxxxxxxxxxx.xxx/xxxxxxxxxx/xxxxxxxxx Medications are covered if they are for urgent or emergent mental conditions or for selected ongoing chronic mental conditions. All medications must be obtained through the pharmacy benefit manager’s network of pharmacies. In order to formalize the medications covered, the BHS Program has developed a formulary. This formulary is restrictive in that only those medications on the formulary list are covered. Further, payments are restricted to generic formulations of medications when they are available. Generics, whether they are available from one or more manufacturers, are covered on the restrictive list. Exclusions from the formulary include medications not listed in the formulary, over- the-counter medications and specific therapeutic classifications relating to conditions outside the scope of the BHS Program. The BHS Program in rare cases may cover a non-formulary drug where one of the following conditions is present: a. All formulary options have been ineffective, or b. Another non-formulary drug is less expensive, or c. There is an overwhelming case specified need, and the diagnosis is within the scope of the BHS Program and is consistent with the prescription. In order to ensure that therapeutic integrity is maintained in the face of cost considerations, only generics rated as therapeutically equivalent (so-called “AB” or “A” rated”), or rated equivalent to the pioneer product by the FDA are covered. a. All medications available in generic must be prescribed as generic. If a physician prescribes a brand name product, then the pharmacy is expected to substitute with a generic when one is available. b. All requests for prior authorizations should be requested and prescribed as generic when available. c. Some medications on the formulary have a quantity limit (QL) on the number of units covered in a month’s supply, and a dollar limit on the maximum payment that the BHS Program will approve. These QL and maximum dollar thresholds are formulary limits on the usual dosage and expense for each medication. Prescriptions for quantities in excess of the QL, or drug costs in excess of the maximum dollar threshold require a prior authorization. d. The BHS Program covers only a 30-day supply of medication at a time. Requests for greater than a 30-day supp...