Common use of Pharmaceutical Products Clause in Contracts

Pharmaceutical Products. Outpatient Pharmaceutical Products, including injectable drugs, and New Pharmaceutical Product, for Covered Health Care Services administered on an outpatient basis in a Hospital, Alternate Facility, Physician's office, or in your home. Benefits are provided for Pharmaceutical Products which, due to their traits (as determined by us), are administered or directly supervised by a qualified provider or licensed/certified health professional. Depending on where the Pharmaceutical Product is administered, Benefits will be provided for administration of the Pharmaceutical Product under the corresponding Benefit category in this Policy. Benefits for medication normally available by a prescription or order or refill are provided as described under Section 10: Outpatient Prescription Drugs. If you require certain Pharmaceutical Products, including specialty Pharmaceutical Products, we may direct you to a Designated Dispensing Entity. Such Dispensing Entities may include an outpatient pharmacy, specialty pharmacy, Home Health Agency provider, Hospital-affiliated pharmacy or hemophilia treatment center contracted pharmacy. If you/your provider are directed to a Designated Dispensing Entity and you/your provider choose not to get your Pharmaceutical Product from a Designated Dispensing Entity, Benefits are not available for that Pharmaceutical Product, unless the provider or its intermediary agrees in writing to accept reimbursement, including copayment, at the same rate as a Designated Dispensing Entity. Certain Pharmaceutical Products are subject to step therapy requirements. This means that in order to receive Benefits for such Pharmaceutical Products, you must use a different Pharmaceutical Product and/or prescription drug product first. You may find out whether a particular Pharmaceutical Product is subject to step therapy requirements by contacting us at xxx.xxxxx.xxx/xxxxxxxx or the telephone number on your ID card. A step therapy requirement may not be imposed if: • The step therapy drug has not been approved by the U.S. Food and Drug Administration (FDA) for the medical condition being treated; or • The prescribing provider provides supporting medical information to us that a Prescription Drug Product: ▪ Was ordered by a prescribing provider for the Covered Person within the past 180 days; and ▪ Based on the professional judgment of the prescribing provider, was effective in treating the Covered Person’s medical condition. • The prescription drug has been approved by the FDA and: ▪ Is being used to treat the Covered Person’s stage four advanced metastatic cancer; and ▪ Use of the prescription drug is consistent with the FDA-approved indication or the National Comprehensive Cancer Network Drugs & Biologics Compendium indication for the treatment of stage four advanced metastatic cancer; and ▪ Is supported by peer-reviewed medical literature. We will have certain programs in which you receive an enhanced Benefit based on your actions such as adherence/compliance to medication or treatment regimens and/or participation in health management programs. You can access information on these programs by contacting us at xxx.xxxxx.xxx/xxxxxxxx or the telephone number on your ID card.