Common use of Benefit Management Programs Clause in Contracts

Benefit Management Programs. To promote appropriate medication use, certain drugs are subject to Pre-Authorization to review and confirm Medical Necessity prior to dispending. As part of this review, some prescriptions may require additional medical information from the prescribing Provider, substitution of equivalent medication, or failure of a preferred drug. If you choose to purchase the medication before the review has been completed, you will pay the full price for the drugs. If the review verifies the medicine use is Medically Necessary and dispensed by a Participating Pharmacy, you may submit a claim for reimbursement. Please see the Claims section in this Agreement for more information. In making these determinations, we take into consideration clinically evidence-based medical necessity criteria, recommendations of the manufacturer, the circumstances of the individual case, FDA guidelines, published medical literature and standard reference compendia. Contact Customer Service for details on which drugs require Pre-Authorization, or see the Pharmacy section on our Web site. Right to Safe and Effective Pharmacy Services State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee your right to know what drugs are covered under this plan, what coverage limitations are in your contract, and how you may be involved in decisions about benefits. For more information about the Prescription Drug coverage policies under this plan, or if you have a question or a concern about your pharmacy benefit, please call us at 1-800-930- 0132. For more information about your rights under the law, or if you think anything you received from this plan may not conform to the terms of your contract, contact the Washington State Office of Insurance Commissioner at 1-800- 562-6900. If you have a concern about the pharmacists or pharmacies serving you, call the Washington State Department of Health at 000-000-0000. Podiatric Care Coverage is provided for Medically Necessary surgical podiatric services, including incision and drainage of infected tissue of the foot, removal of lesions of the foot, removal or debridement of infected toenails, and treatment of fractures and dislocations of bones of the foot. Routine foot care, such as the treatment of corns, calluses, non- surgical care of toenails, fallen arches and other symptomatic complaints of the feet are not covered, except for diabetics.