Common use of Pharmacy Benefits Manager Clause in Contracts

Pharmacy Benefits Manager. The pharmacy benefits available to You under this Contract are managed by Our Pharmacy Benefits Manager (PBM). The PBM is a pharmacy benefits management company with which We contract to manage Your pharmacy benefits. The PBM has a nationwide network of retail pharmacies, a Mail Service pharmacy, and provides clinical management services. The management and other services the PBM provides include, among others, making recommendations to, and updating, the Covered Prescription Drug list (also known as a Formulary) and managing a network of retail pharmacies and, operating a Mail Service pharmacy. The PBM, in consultation with Us, also provides services to promote and enforce the appropriate use of pharmacy benefits, such as review for possible excessive use, recognized and recommended dosage regimens, Drug interactions or Drug/pregnancy concerns. You may request a copy of the Covered Prescription Drug list by calling the Customer Service telephone number on the back of Your I.D. Card. The Covered Prescription Drug list is subject to periodic review and amendment. Inclusion of a Drug or related item on the Covered Prescription Drug list is not a guarantee of Coverage. You may request a list of Pharmacies in the PBM network by calling the customer service number listed on the back of Your I.D. Card. Prescription Drugs, unless otherwise stated below, must be Medically Necessary and not Experimental/Investigative, in order to be Covered Health Services. For certain Prescription Drugs, the prescribing Physician may be asked to provide additional information before the PBM and/or the Contract can determine Medical Necessity. The Contract may, in its sole discretion, establish quantity and/or age limits for specific Prescription Drugs which the PBM will administer. Covered Health Services will be limited based on Medical Necessity, quantity and/or age limits established by the Contract, or utilization guidelines. Prior Authorization may be required for certain Prescription Drugs (or the prescribed quantity of a particular Drug). Prior Authorization helps promote appropriate utilization and enforcement of guidelines for Prescription Drug benefit Coverage. At the time You fill a prescription, the Participating Pharmacist is informed of the Prior Authorization requirement through the pharmacy’s computer system. The PBM uses pre-approved criteria, developed by Our Pharmacy and Therapeutics Committee which is reviewed and adopted by Us. We, or the PBM may contact Your Provider if additional information is required to determine whether Prior Authorization should be granted. We communicate the results of the decision to both You and Your Provider. If Prior Authorization is denied, You have the right to appeal through the appeals process outlined in Article 8. For a list of the current Drugs requiring Prior Authorization, please contact the Pharmacy Customer Service telephone number on the back of Your I.D. card. The Covered Prescription Drug list is subject to periodic review and amendment. Inclusion of a Drug or related item on the Covered Prescription Drug list is not a guarantee of Coverage under Your Contract. Refer to the Prescription Drug benefit sections in this Contract for information on Coverage, limitations and exclusions. Your Participating Provider or Participating Pharmacist may check with Us to verify Covered Prescription Drugs, any quantity and/or age limits, or applicable Brand or Generic Drugs recognized under the Contract.  Therapeutic Substitution of Drugs is a program approved by Us and managed by the PBM. This is a voluntary program designed to inform Enrollees and Physicians about possible alternatives to certain prescribed Drugs. We, or the PBM, may contact You and Your prescribing Physician to make You aware of substitution options. Therapeutic substitution may also be initiated at the time the prescription is dispensed. Only You and Your Physician can determine whether the therapeutic substitute is appropriate for You. For questions or issues involving therapeutic Drug substitutes, call the Customer Service telephone number on the back of Your I.D. card. The therapeutic Drug substitutes list is subject to periodic review and amendment.  Step Therapy. Step therapy protocol means that an Enrollee may need to use one type of medication before another. The PBM monitors some Prescription Drugs to control utilization, to ensure that appropriate prescribing guidelines are followed, and to help Enrollees access high quality yet cost effective Prescription Drugs. If a Physician decides that the monitored medication is needed the Prior Authorization process is applied.

Pharmacy Benefits Manager. The pharmacy benefits available to You under this Contract are managed by Our Pharmacy Benefits Manager (PBM). The PBM is a pharmacy benefits management company with which We contract to manage Your pharmacy benefits. The PBM has a nationwide network of retail pharmacies, a Mail Service pharmacy, and provides clinical management services. The management and other services the PBM provides include, among others, making recommendations to, and updating, the Covered Prescription Drug list (also known as a Formulary) and managing a network of retail pharmacies and, operating a Mail Service pharmacy. The PBM, in consultation with Us, also provides services to promote and enforce the appropriate use of pharmacy benefits, such as review for possible excessive use, recognized and recommended dosage regimens, Drug interactions or Drug/pregnancy concerns. You may request a copy of the Covered Prescription Drug list by calling the Customer Service telephone number on the back of Your I.D. Card. The Covered Prescription Drug list is subject to periodic review and amendment. Inclusion of a Drug or related item on the Covered Prescription Drug list is not a guarantee of Coverage. You may request a list of Pharmacies in the PBM network by calling the customer service number listed on the back of Your I.D. Card. Prescription Drugs, unless otherwise stated below, must be Medically Necessary and not Experimental/Investigative, in order to be Covered Health Services. For certain Prescription Drugs, the prescribing Physician may be asked to provide additional information before the PBM and/or the Contract can determine Medical Necessity. The Contract may, in its sole discretion, establish quantity and/or age limits for specific Prescription Drugs which the PBM will administer. Covered Health Services will be limited based on Medical Necessity, quantity and/or age limits established by the Contract, or utilization guidelines. Prior Authorization may be required for certain Prescription Drugs (or the prescribed quantity of a particular Drug). Prior Authorization helps promote appropriate utilization and enforcement of guidelines for Prescription Drug benefit Coverage. At the time You fill a prescription, the Participating Pharmacist is informed of the Prior Authorization requirement through the pharmacy’s computer system. The PBM uses pre-approved criteria, developed by Our Pharmacy and Therapeutics Committee which is reviewed and adopted by Us. We, or the PBM may contact Your Provider if additional information is required to determine whether Prior Authorization should be granted. We communicate the results of the decision to both You and Your Provider. If Prior Authorization is denied, You have the right to appeal through the appeals process outlined in Article 8. For a list of the current Drugs requiring Prior Authorization, please contact the Pharmacy Customer Service telephone number on the back of Your I.D. card. The Covered Prescription Drug list is subject to periodic review and amendment. Inclusion of a Drug or related item on the Covered Prescription Drug list is not a guarantee of Coverage under Your Contract. Refer to the Prescription Drug benefit sections in this Contract for information on Coverage, limitations and exclusions. Your Participating Provider or Participating Pharmacist may check with Us to verify Covered Prescription Drugs, any quantity and/or age limits, or applicable Brand or Generic Drugs recognized under the Contract.  Therapeutic Substitution If We remove a Prescription Drug from Our Formulary or change the cost sharing requirements that apply to a Prescription Drug or change the utilization review standards that apply to a Prescription Drug We will do one of Drugs the following for any Enrollee who has been prescribed the Prescription Drug in the 12 months preceding the removal or change. o Send written notice of the removal or change at least 60 days before the removal or change is a program approved by Us and managed by the PBM. This is a voluntary program designed to inform Enrollees and Physicians about possible alternatives to certain prescribed Drugs. Weeffective, or the PBM, may contact You and Your prescribing Physician to make You aware of substitution options. Therapeutic substitution may also be initiated at o At the time of a request to refill a Prescription Drug, provide written notice of the prescription is dispensed. Only You removal or change and Your Physician can determine whether provide a 60 day supply of the therapeutic substitute is appropriate for You. For questions Prescription Drug under the terms that applied before the removal or issues involving therapeutic Drug substitutes, call the Customer Service telephone number on the back of Your I.D. card. The therapeutic Drug substitutes list is subject to periodic review and amendment.  Step Therapy. Step therapy protocol means that an Enrollee may need to use one type of medication before another. The PBM monitors some Prescription Drugs to control utilization, to ensure that appropriate prescribing guidelines are followed, and to help Enrollees access high quality yet cost effective Prescription Drugs. If a Physician decides that the monitored medication is needed the Prior Authorization process is appliedchange.