Common use of Generic Drugs and Generic Substitution Clause in Contracts

Generic Drugs and Generic Substitution. Generic drugs have the same active ingredients, must meet the same FDA rules for safety, purity and potency, and must be given in the same form (tablet, capsule, cream) as the brand‐name Drug. When you are prescribed a brand‐name drug and a generic option is available, your pharmacy will automatically fill the prescription using the generic drug. If, for medical reasons, you require the brand‐name drug not listed on the formulary, you can request your Provider obtain Prior Approval from our Pharmacy Benefits Manager of the brand‐name drug. Your Provider will need to submit clinical information to support why you need the brand‐name drug instead of the generic. If Prior Approval is granted, you will pay the applicable cost associated with the brand‐name drug as described on the formulary. In the event the brand‐name drug is not on the formulary, the drug will be covered as a Tier 4 or Tier 5 drug (cost‐sharing will apply as listed in the Schedule of Benefits). Your Provider can also request (or submit on your behalf) a prescription for a brand‐name drug listed on the formulary where there is a generic equivalent available, by writing “dispense as written” on the prescription. This requires the pharmacy to fill the prescription for the brand‐name drug. If “dispense as written” is on the prescription, you will pay the non‐preferred brand drug cost‐sharing. If your Provider does not deem the brand‐name drug medically necessary and you choose to have the pharmacy fill the prescription with the brand‐name drug, you will pay the non‐preferred brand drug cost‐sharing plus a penalty of the difference in the price between the brand‐name drug and generic drug. The penalty does not apply to your Out‐of‐Pocket costs. The penalty even applies after you have met your Out‐of‐Pocket limit.

Generic Drugs and Generic Substitution. Generic drugs have the same active ingredients, must meet the same FDA rules for safety, purity and potency, and must be given in the same form (tablet, capsule, cream) as the brand‐name brand-name Drug. When you are prescribed a brand‐name brand-name drug and a generic option is available, your pharmacy will automatically fill the prescription using the generic drug. If, for medical reasons, you require the brand‐name brand-name drug not listed on the formulary, you can request your Provider obtain Prior Approval from our Pharmacy Benefits Manager of the brand‐name brand-name drug. Your Provider will need to submit clinical information to support why you need the brand‐name brand-name drug instead of the generic. If Prior Approval is granted, you will pay the applicable cost associated with the brand‐name brand-name drug as described on the formulary. In the event the brand‐name drug is not on the formulary, the drug will be covered as a Tier 4 or Tier 5 drug (cost‐sharing will apply as listed in the Schedule of Benefits). Your Provider can also request (or submit on your behalf) a prescription for a brand‐name brand-name drug listed on the formulary where there is a generic equivalent available, by writing “dispense as written” on the prescription. This requires the pharmacy to fill the prescription for the brand‐name brand-name drug. If “dispense as written” is on the prescription, you will pay the non‐preferred non-preferred brand drug cost‐sharingcost-sharing. If your Provider does not deem the brand‐name brand-name drug medically necessary and you choose to have the pharmacy fill the prescription with the brand‐name brand-name drug, you will pay the non‐preferred non-preferred brand drug cost‐sharing cost-sharing plus a penalty of the difference in the price between the brand‐name brand-name drug and generic drug. The penalty does not apply to your Out‐of‐Pocket Out-of-Pocket costs. The penalty even applies after you have met your Out‐of‐Pocket Out-of-Pocket limit.