Pharmacy Provisions. Company shall disclose to Plan Members whether that Plan Member’s health plan uses a formulary and, if so, explain what a formulary is, how Company determines which prescription medications are included in the formulary, and how often Company reviews the formulary list. When Company provides pharmacy coverage, Company shall make formulary information available to Plan Members. Company shall maintain the process, as reasonably amended, for covering formulary-excluded medications when medically necessary that is in place on the Execution Date. Company shall cover drugs prescribed for non-approved, medically necessary use except to the extent that the applicable Plan Member’s Plan expressly excludes such prescriptions; provided that Company shall retain the right to pre-certify coverage of specific medications for non- approved use. Company’s disclosure concerning pre- certification and potential restrictions on non-approved use of prescription medications shall be similar in substance to disclosure concerning formularies, as described above. The training and policy manual materials promulgated and training efforts implemented to effectuate the commitment set forth in this § 7.30(j), as well as any disclosure forms or methods, shall be included in the Certification to be filed annually and at the end of the Effective Period.
Pharmacy Provisions. Company shall disclose to Plan Members whether that Plan Member’s health plan uses a formulary and, if so, explain what a formulary is, how Company determines which prescription medications are included in the formulary, and how often Company reviews the formulary list. When Company provides pharmacy coverage, Company shall make formulary information available to Plan Members. Company shall maintain the process, as reasonably amended, for covering medications not included in the formulary when medically necessary that is in place on the Execution Date. Company will continue to provide coverage for off-label uses of pharmaceuticals that have been approved by the FDA (but not approved for the prescribed use) provided that the drug is not contraindicated by the FDA for the off-label use prescribed, and that the drug has been proven safe, effective and accepted for the treatment of the specific medical condition for which the drug has been prescribed, as evidenced by supporting documentation in any one of the following (1) the American Hospital Formulary Service Drug Information or the United States Pharmacopeia Drug Information; or (2) results of controlled clinical studies published in at least two peer-reviewed national professional medical journals. Company shall retain the right to pre-certify coverage of specific medications for non-approved use. Company’s disclosure concerning pre-certification and potential restrictions on non-approved use of prescription medications shall be similar in substance to disclosure concerning formularies, as described above.
Pharmacy Provisions. Company shall disclose to Plan Members whether that Plan Member’s health plan uses a drug list and, if so, explain what a drug list is, how Company determines which prescription medications are included in the drug list, and how often Company reviews the drug list. When Company provides pharmacy coverage, Company shall make drug list information available to Plan Members. Company shall maintain the process that is in place on the Effective Date, as reasonably amended by Company from time to time, for covering medications not included in the drug list when Medically Necessary. Company will continue to provide coverage for off-label uses of pharmaceuticals that have been approved by the FDA (but not approved for the prescribed use) provided that the drug is not contraindicated by the FDA for the off-label use prescribed, and that the drug has been proven safe, effective and accepted for the treatment of the specific medical condition for which the drug has been prescribed, as evidenced by supporting documentation in any one of the following (1) the American Hospital Formulary Service Drug Information or the United States Pharmacopeia Drug Information; or
Pharmacy Provisions
