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 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 at 1-855-624-6463. SAMPLE Determination of coverage is made by Health Options and our Pharmacy Benefits Manager (PBM). Your Health Options’ 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
Appears in 1 contract
Samples: Member Benefit Agreement
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-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 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 cost‐sharing for a particular tier, you should refer to your Schedule of Benefits. The cost-sharing 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-sharingcost‐sharing. Medications obtained by your Provider are applied to your medical benefit cost-sharingcost‐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 1-855-624-6463Services. SAMPLE Determination of coverage is made by Community Health Options and our Pharmacy Benefits Manager (PBM). Your Community Health Options’ formulary is evaluated on an ongoing basis, basis and could change. Community Health Options does not send separate notices if a brand- 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 Out‐of‐Pocket Costs, please contact Member Services at 1-855-624-6463 (TTY/TDD: 711)Services. For access to the formulary, please visit our website at xxxxx://xxx.xxxxxxxxxxxxx.xxx/Documents/formulary.
Appears in 1 contract
Samples: Member Benefit Agreement
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 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 at 1-855-624-6463. SAMPLE Determination of coverage is made by Health Options and our Pharmacy Benefits Manager (PBM). Your Health Options’ 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.
Appears in 1 contract
Samples: Member Benefit Agreement
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-dateup‐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 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 cost‐sharing for a particular tier, you should refer to your Schedule of Benefits. The cost-sharing 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-sharingcost‐sharing. Medications obtained by your Provider are applied to your medical benefit cost-sharingcost‐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 1-855-624-6463Services. SAMPLE Determination of coverage is made by Community Health Options and our Pharmacy Benefits Manager (PBM). Your Community Health Options’ formulary is evaluated on an ongoing basis, basis and could change. Community Health Options does not send separate notices if a brand- 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 Out‐of‐Pocket Costs, please contact Member Services at 1-855-624-6463 (TTY/TDD: 711)Services. For access to the formulary, please visit our website at xxxxx://xxx.xxxxxxxxxxxxx.xxx/Documents/formulary
Appears in 1 contract
Samples: Member Benefit Agreement
