Formulary a. The Contractor shall make available in electronic or paper form, the following information about its formulary:
i. Which medications are covered (both generic and name brand); and
ii. What tier each medication resides.
b. Formulary drug lists shall be made available on the Contractor’s website in a machine-readable file and format as specified by the Secretary.
Formulary. The MCO must make available, in electronic or paper format, the following information about its formulary, consistent with 42 CFR §438.10(i):
3.12.7.1 Which medications are covered (both generic and name brand);
3.12.7.2 What tier each medication is on;
3.12.7.3 The formulary document must be posted on the MCO’s web site. The document must meet all of the List of Covered Drugs Guidelines and may not differ from the State-approved paper copy. The MCO web site must include the formulary as a machine readable file, in a format specified by CMS. [42 CFR §438.10(i)]
Formulary a listing of Prescription Drugs and Over-the-Counter Drugs selected by the Plan based on an analysis of clinical efficacy, unique value, safety, and pharmacoeconomic impact. This listing is subject to periodic review and modification by the Plan or a designated committee of Physicians or pharmacists.
Formulary. Community Health Options reviews and selects drugs for the formulary that will be safe, effective, and as affordable as possible. These formulary selections are based on their therapeutic value, side effects, and cost compared to similar medications. Community Health Options regularly evaluates the formulary to ensure it is up to date. Updates to the formulary will be posted to the Community Health Options website. Adverse formulary changes involving the removal of a drug from the formulary or moving it to a different cost‐sharing tier will be made with at least 60 days’ advance written notice, unless when a prescription drug is being removed from the formulary because of concerns about safety. The formulary contains information for each drug, including the tier, and designation if Prior Approval (PA), step therapy (ST) requirements (if any), quantity limits (QL) (a limit to how much of the drug the Member may receive each fill and/or a limit of fills per month) and any other requirements that apply. No step therapy is required if the Member has tried the alternative medication under the Member’s current health plan or a prior health plan or the Member is stable on the alternative medication. Coverage of drugs, including those not otherwise identified by qualifiers such as PA/ST/QL, may be subject to safety screenings and other clinical edits in the course of claims transaction processing. To determine the cost‐sharing for a particular tier, you should refer to your Schedule of Benefits. The cost‐sharing described on your Schedule of Benefits. You can fill your prescriptions through participating Retail Pharmacies, home delivery, and/or specialty pharmacies as your benefit permits. Medications dispensed by a pharmacy are subject to prescription drug cost‐sharing. Medications obtained by your Provider are applied to your medical benefit cost‐sharing. When filling prescriptions, you must be eligible for coverage on the date the prescription is filled. If applicable and you are in the 2nd or 3rd month of a grace period, as described in Section 3.D, your pharmacy claim will be denied. You may submit a pharmacy reimbursement request after you have cleared the grace period by paying all outstanding premiums as described in Section 3.D. If you feel you have been incorrectly denied coverage, contact Member Services. Determination of coverage is made by Community Health Options and our Pharmacy Benefits Manager (PBM). Your Community Health Options’ formulary is eva...
Formulary. No changes to the formulary shall be effective until thirty (30) days following the date written notice is delivered to the Union. Tier changes to the formulary will happen once per year.
Formulary a list of both Brand and Generic Prescription Drugs reviewed and updated by a Pharmacy and Therapeutics Committee. The Formulary is subject to periodic review and modification. The Formulary applies only to Prescription Drugs covered under this Program. The Formulary does not apply to Inpatient medications or to medications administered by a Professional Provider. The level of benefits You receive under this Program will be affected by a Prescription Drug's Generic/Brand status on the Formulary.
Formulary. A list of drugs covered by the pharmacy program claims administrator and as allowed by the plan administrator.
Formulary. Health Options reviews and selects drugs for the formulary that will be safe, effective, and as affordable as possible. These formulary selections are based on their therapeutic value, side effects, and cost compared to similar medications. Health Options regularly evaluates the formulary to ensure it is up-to-date. Updates to the formulary will be posted to the Health Options website. Adverse formulary changes will be made with at least 60 days’ advance written notice, unless when a prescription drug is being removed from the formulary because of concerns about safety. The formulary contains information for each drug, including the tier, and designation if Prior Approval, step therapy requirements (if any), quantity limits (a limit to how much of the drug the Member may receive each fill and/or a limit of fills per month) and any other requirements that apply. To determine the cost-sharing for a particular tier, you should refer to your Schedule of Benefits. You can fill your prescriptions through participating Retail Pharmacies, home delivery, and/or specialty pharmacies. Medications dispensed by a pharmacy are subject to prescription drug cost-sharing. Medications obtained by your Provider are applied to your medical benefit cost-sharing. When filling prescriptions, you must be eligible for coverage on the date the prescription is filled. If applicable and you are in the 2nd or 3rd month of a grace period, as described in Section 3.D, your pharmacy claim will be denied. You may submit a pharmacy reimbursement request after you have cleared the grace period by paying all outstanding premiums as described in Section 3.D. If you feel you have been incorrectly denied coverage, contact Member Services at 1-855-624-6463. Determination of coverage is made by Health Options and our Pharmacy Benefits Manager (PBM). Your formulary is evaluated on an ongoing basis, and could change. Health Options does not send separate notices if a brand-name drug becomes available as a generic drug. The pharmacist usually tells you this information when you fill your next prescription. If you have more questions about the formulary or your Out-of-Pocket Costs, please contact Member Services at 1-855-624-6463 (TTY/TDD: 711). For access to the formulary, please visit our website at xxxxx://xxx.xxxxxxxxxxxxx.xxx/Documents/formulary
Formulary. A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list. A hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients.
Formulary. PIC uses its drug formulary to determine which benefit level applies to a specific prescription drug. The formulary is subject to periodic review by XXX’s Pharmacy and Therapeutics Quality Subcommittee and modification by PIC, including at the start of or during the plan year. A current list of drugs on PIC’s formulary for individual plans may be obtained by accessing PIC’s website at xxxxx://xxx.xxxxxxxxxxxx.xxx/pharmacy-information/formulary and choosing “Individual Plans” or by calling PIC Customer Service. PIC will provide reasonable advance notice to you if, during the plan year, a prescription drug which you have previously received during such plan year and which PIC has previously considered to be an eligible charge under this contract is removed from the formulary or if such prescription drug is placed in a higher cost-sharing tier during the plan year. You have a right to appeal the decision or to request an exception to gain access to a non-formulary drug when clinically appropriate and not otherwise covered under this contract. Refer to the section entitled “Internal Appeals Process” for details on how to appeal. Refer to the paragraphs entitled “Exceptions” below for details on how to request an exception.
