Generic Substitution. If a brand is dispensed when there’s a generic equivalent available, the member will be responsible for the brand copayment plus the difference in cost between the brand and the generic drug.
Generic Substitution. The maximum amount payable for an eligible brand name drug will be limited to the lowest priced item in the appropriate generic category. Limitations and Exclusions No benefit is payable for the portion of expenses for which reimbursement is provided by a government expenses for drugs which, in Mutual's opinion, are experimental, expenses for dietary supplements, vitamins and infant foods, expenses for contraceptives (other than oral), expenses for smoking cessation aids, expenses for drugs if they are used for the treatment of infertility, the yearly or per prescription deductible on drugs that are eligible under the Ontario Drug Benefit plan and are purchased by you or your insured spouse who is age or over. Extended Health Primary and Secondary Pay Direct Drug Benefit May Extended Health Vision Benefit Eligible Expenses Eligible expenses mean reasonable and customary charges for the following items of expense eye examinations by an optometrist, but for not more than one examination in a period of months (12 months for a dependent child under age 18); eyeglasses and contact lenses provided such appliances are necessary for the correction of vision and are prescribed by an ophthalmologist or optometrist, and repairs to such appliances, subject to maximum total eligible expenses of during the month period ending on the date an eligible expense for such appliances is incurred; eyeglasses and contact lenses where an ophthalmologist certifies that such appliances are necessary as a result of a surgical procedure or for the treat- ment of keratoconus subject to maximum total lifetime eligible expenses of in respect of any one surgical procedure or for the treatment of keratoconus.
Generic Substitution. The drug plan will be modified as necessary to require generic substitution for drugs covered by the plan unless otherwise prescribed by the employee's doctor.
Generic Substitution. When there is a generic version of a brand-name drug available, our network pharmacies may recommend and/or provide you the generic version, unless your doctor has told us that you must take the brand- name drug and we have approved this request. You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary or on our xxx.xxx.xxx/xxxxxxxx, or by calling Customer Service. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren’t able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception (which is a type of coverage determination). See Section 5 for more information about how to request an exception. Drug utilization review We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as: • Possible medication errors • Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition • Drugs that are inappropriate because of your age or gender • Possible harmful interactions between drugs you are taking • Drug allergies • Drug dosage errors If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem. Medication therapy management programs We offer medication therapy management programs at no additional cost to members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors. We may contact members who qualify for these programs. If we contact you, we hope you will join so that we can help you manage your medications. Remember, you don’t need to pay anything extra to participate. If you are selected to join a medication therapy m...
