Using Your Pharmacy BenefitsKYHC, in consultation with a team of health care providers, has developed a list of medications which represent the prescription therapies believed to be a necessary part of a quality treatment program referred to as the “formulary”. KYHC will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a KYHC network pharmacy, and other plan rules are followed. Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we will notify affected members of the change at least 60 calendar days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The drugs in our formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, heart disease. If you know what your drug is used for, look for the category name in the Category Index. Then look under the category name for your drug. If you are not sure what category to look under, you should look for your drug in the Drug Index. The Drug Index provides an alphabetical list of all of the drugs included in the formulary. Both brand name drugs and generic drugs are listed in the Drug Index. Look in the Drug Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Drug Index and find the name of your drug in the first column of the list. KYHC covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: a prior authorization, limits on quantity, step therapy (requiring the use of another drug first) and therapeutic interchange (the use of another medication with the same therapeutic purpose). Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Over The Counter (OTC) drugs are non-prescription drugs that are not normally covered by a health plan. KYHC pays for certain OTC drugs. KYHC will provide these OTC drugs at no cost to you. The cost to KYHC of these OTC drugs will not count toward your total Part D drug costs. If you cannot find your drug on our formulary you should first contact Member Services and ask if your drug is covered. If you learn that KYHC does not cover your drug you can ask Member Services for a list of similar drugs that are covered by KYHC. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by KYHC. A second option is ask for an exception to be made for your drug. You may ask KYHC to make an exception to these restrictions or limits, to cover a drug that is not on the formulary, or for a list of other drugs that may treat your health condition. There are several types of exceptions that can be made. You may request that we cover the drug even if it is not in our formulary. If this is approved the medication will be covered at a pre-determined cost-sharing level. You may also ask that the current cost sharing of a formulary drug be lowered. And for those medications on which there is a quantity limit, you may request that the limit be raised. Generally, KYHC will only approve your request for an exception if the alternative drugs included on our formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. When you are requesting an exemption you should submit a written statement providing information that supports the request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. If you have questions about your pharmacy benefits please call Member Services at 1 (888) 821-5516. If you would like to review our formulary, please visit our website at www.mykyhc.org. Select "Formulary Drug List.” The Formulary Drug List search tool lets you search for your drug by name or drug type. What Is A Copay?For every plan of coverage there are certain charges that are the responsibility of the member. For any service there may be a copayment (copay). This is a specific dollar amount of the Maximum Allowable Amount for covered services that you must pay. The Copayment does not apply to any deductible that you are required to pay. Your Copayment will be the lesser of the amount shown in the Schedule of Benefits or the amount charged by the provider. Coinsurance is a specific percentage of the Maximum Allowable Amount for covered services that is indicated in the Schedule of Benefits, which you must pay. Coinsurance normally applies after the Deductible that you are required to pay. Your Deductible is the dollar amount of covered services, listed in the Schedule of Benefits, which you must pay before KYHC will pay for those covered services in each benefit period. Each of these amounts vary depending on the service rendered and the plan selected. For specific details that apply to your plan please see your Schedule of Benefits. | | Pharmacy Info Email Phone
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