Prior Authorization and Progressive Medication Program Sample Clauses
The Prior Authorization and Progressive Medication Program clause establishes requirements for obtaining approval before certain medications are dispensed and mandates the use of step therapy protocols. Under this clause, patients may need to try and fail less expensive or preferred medications before coverage is granted for more costly or specialized drugs, and healthcare providers must submit documentation to justify the need for exceptions. This clause helps control prescription drug costs and ensures that clinically appropriate, cost-effective treatments are considered before more expensive options are approved.
Prior Authorization and Progressive Medication Program. Your Prescription Medication coverage may require Prior Authorization, and such Prior Authorization may include the Progressive Medication Program for certain covered medications. The prescribing Physician or the Participating Pharmacy must obtain approval (prior to dispensing) from AvMed. The list of Prescription Medications requiring Prior Authorization is subject to periodic review and modification by ▇▇▇▇▇ and may be amended without notice. A copy of the list of covered Prescription Medications, drugs requiring Prior Authorization and drugs that are a part of the Progressive Medication Program are available from AvMed’s Member Engagement Center or from the AvMed website. The Progressive Medication Program encourages the use of therapeutically-equivalent lower-cost medications by requiring certain medications to be utilized to treat a Condition prior to approving another medication for that Condition. The Progressive Medication Program includes the first-line use of preferred medications that are proven to be safe and effective for a given Condition and can provide the same health benefit as more expensive non-preferred medications at a lower cost.