Common use of Generic Step Therapy Clause in Contracts

Generic Step Therapy. a program that requires plan members use cost-effective alternatives within the same therapeutic class, as first line therapy before brand name prescriptions are covered. The program includes an appeals process that would allow the member and provider to request an exception to this requirement in medically necessary circumstances. The County shall provide written and electronic notification to the Union and electronic notification to all Bargaining Unit Members of any medications and/or targeted classes that are to be added to the generic step therapy list at least 30 calendar days prior to the effective date of the change(s). The PBM shall also provide written notice to an affected member whenever any medication(s) he/she is taking will be added to the generic step therapy list at least 30 calendar days prior to the effective date of the change(s). Notification to the affected member shall include a list of generic alternative medications that 10 Per action taken on May 26, 2011, the County Council did not approve full funding for this provision. On that date, the Council adopted a different cost-sharing arrangement for bargaining unit employees, to become effective on January 1, 2012. See Appendix V. 11 For the duration of this contract (July 1, 2017 – June 30, 2019) PBM’s pharmacy network refers to CVS Pharmacies. the member may take to the treating physician to discuss treatment options. However, any member who is taking a specialty medication at the time of notification shall be grandfathered, meaning that he/she shall be allowed to continue taking the non-generic specialty medication at the member’s cost identified in the prescription plan negotiated by the Union and the Employer for as long as his/her treating physician prescribes such medication. In instances where a member’s prescription is rejected because a generic alternative exists and the member’s doctor is unavailable for consultation, the Union, on behalf of the member, may petition 12 the County benefit office to intervene with the PBM and request that the doctor’s prescription be filled as written. The County agrees to work with the Union and the PBM to ensure the member does not go without the needed medication.

Generic Step Therapy. a program that requires plan members use cost-effective alternatives within the same therapeutic class, as first line therapy before brand name prescriptions are covered. The program includes an appeals process that would allow the member and provider to request an exception to this requirement in medically necessary circumstances. The County shall provide written and electronic notification to the Union and electronic notification to all Bargaining Unit Members of any medications and/or targeted classes that are to be added to the generic step therapy list at least 30 calendar days prior to the effective date of the change(s). 14 Per Action taken on May 26, 2011, the County Council did not approve full funding for this provision. On that date, the Council adopted a different cost-sharing arrangement for bargaining unit employees to become effective on January 1, 2012. See Appendix V. 15 For the duration of this contract (July 2017- June 30, 2019) PBM's pharmacy network refers to CVS Pharmacies. The PBM shall also provide written notice to an affected member whenever any medication(s) he/she is taking will be added to the generic step therapy list at least 30 calendar days prior to the effective date of the change(s). Notification to the affected member shall include a list of generic alternative medications that 10 Per action taken on May 26, 2011, the County Council did not approve full funding for this provision. On that date, the Council adopted a different cost-sharing arrangement for bargaining unit employees, to become effective on January 1, 2012. See Appendix V. 11 For the duration of this contract (July 1, 2017 – June 30, 2019) PBM’s pharmacy network refers to CVS Pharmacies. the member may take to the treating physician to discuss treatment options. However, any member who is taking a specialty medication at the time of notification shall be grandfathered, meaning that he/she shall be allowed to continue taking the non-generic specialty medication at the member’s cost identified in the prescription plan negotiated by the Union and the Employer for as long as his/her treating physician prescribes such medication. In instances where a member’s prescription is rejected because a generic alternative exists and the member’s doctor is unavailable for consultation, the Union, on behalf of the member, may petition 12 petition16 the County benefit office to intervene with the PBM and request that the doctor’s prescription be filled as written. The County agrees to work with the Union and the PBM to ensure the member does not go without the needed medication.