1) No two formularies are the same.
2) QualChoice will make the following prescription drug accommodations for members of new groups:
a) When a medication covered under a previous plan is not covered under the QualChoice plan, and that medication is one that is important to be taken every single day, QualChoice will accommodate with a one month refill allowed, and expect the member and his or her physician to arrange an alternate medication before the next refill is due.
b) When a medication previously filled at a retail pharmacy now requires being filled at a specialty pharmacy, a one month refill will be allowed with the expectation that arrangements will be made with one of the QualChoice contracted specialty pharmacies before the next refill is due.
c) When a medication previously refilled routinely requires adherence to a step-therapy protocol, if the pharmacist will identify to the pharmacy benefit manager who manages the QualChoice program that this is a medication that has been taken chronically by the member, it will be approved.
d) When a medication requires preauthorization, QualChoice will waive that preauthorization process for ONE refill only to permit the member and his or her physician the time to comply with the process.
1) When people change health plans, they often find that medications move to different member payment amounts than they were accustomed to, or that medications that were previously covered are no longer covered in the new plan.
2) QualChoice will make the following accommodations for members of new groups, to permit smooth transition between plans:
e) When a medication or its equivalent is available over the counter, the member will be expected to use the over-the-counter medication unless the prescription medication is on the QualChoice formulary.
f) When a medication or its equivalent is available from QualChoice at a different tier from the previous coverage, the member will be responsible for the QualChoice member copayment.
g) When a medication is one that is a plan exclusion (such as infertility medication, vitamins, nutritional supplements or cosmetic medication) no exception to the rule will be made (except in cases of extreme need – see a) above).
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.