Insulin for Diabetes Cost Sharing Cap. The Copayment amount for a preferred Formulary prescription insulin drug or a Medically Necessary alternative will be Covered at an amount not to exceed a total of $25.00 per 30-day supply. What is a Formulary? A drug Formulary, or preferred drug list, is a continually updated list of medications and related products supported by current evidence-based medicine, judgment of physicians, pharmacists and other experts in the diagnosis and treatment of disease and preservation of health. The primary purpose of the Formulary is to encourage the use of safe, effective and most affordable medications. Presbyterian Health Plan administers a closed Formulary, which means that Non-Formulary drugs are not routinely reimbursed by the plan. Medical exception policies provide access to Non-Formulary medication when Medical necessity is established. The medications listed on the Formulary are subject to change pursuant to the management activities of Presbyterian Health Plan. For the most up-to-date Formulary drug information visit xxxxx://xxxxxx.xxxxxxxxxxxxxxxxxx.xxx/Search.aspx?siteCode=0324498195. Presbyterian will provide material that contains in a clear, conspicuous and readily understandable form, a full and fair disclosure of the plan’s benefits, limitations, exclusions, conditions of eligibility and Prior Authorization requirements, within a reasonable time after enrollment and at subsequent periodic times as appropriate. Can the Formulary change during the year? The Formulary can change throughout the year. Some reasons why it can change include: • New drugs are approved • Existing drugs are removed from the market • Prescription drugs may become available over the counter (without a prescription) • Brand-name drugs lose patient protection and generic versions become available. • Changes based on new clinical guidelines If we remove drugs from our Formulary, add quantity limits, prior authorization, and/or step therapy restrictions on a drug; or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective. If your plan provides prescription drug benefits that applies a deductible or coinsurance cost share, Presbyterian will not make any of the following changes to coverage for a prescription drug within 120 days of any previous change to coverage for that prescription drug, unless a generic version of the prescription drug is available. • Reclassify a drug to a higher tier of the...
Insulin for Diabetes Cost Sharing Cap. The Copayment amount for a preferred Formulary prescription insulin drug or a Medically Necessary alternative will be Covered at an amount not to exceed a total of $25.00* per 30-day supply. *Copayments are subject to Deductible first.
