Plan requires members to complete the application process, in good faith, for alternate funding programs…… …
See part of Summary Plan Document below describing role of PaydHealth towards controlling specialty drug costs. Accessing manufacturers patient assistance programs is part of the strategy:
The Plan contracted with PaydHealth to be its specialty healthcare advocacy firm for financial case management, replacing PillarRx (formerly IPC/Evergreen Rx) which was the Plan’s specialty drug case manager.
The purpose of the advocacy firm is to provide financial case management for Specialty Drugs, products, and services included on the Specialty List (SL), in order to reduce the cost of Specialty Drugs, products and services for you and the Plan.
Specialty Drugs, products, and services included and noted on the Specialty List that have been specifically designated by the Fund are subject to prior authorization, step-therapy, and administrative review prior to the specified Plan coverage limits applying as shown on the Schedule of Benefits tables in the SPD. PaydHealth will work to reduce your and the Plan’s costs for these listed items.
The Plan requires you to enroll in the Specialty Healthcare Advocacy Program. Additionally, the Plan requires that you complete the application process, in good faith, for alternate funding programs identified by your Specialty Healthcare Case Coordinator. Completing the enrollment application, meeting medical necessity and step-therapy criteria are prerequisites to receiving any coverage under the Plan for Specialty Drugs, products, or healthcare included on the Plan’s SL.
If you choose not to enroll in the Specialty Healthcare Advocacy Program, the co-insurance or out- of-pocket cost for Specialty Drugs will be 100% of the pharmacy billed charges and your costs will not apply to your annual maximum amount or deductible.
The Plan is sponsoring this program and you will not be responsible for any payments to the program as a participant in the Plan. However, you may be required to pay a portion of the cost to acquire your Specialty Drug, product or service.
Advocates from the Specialty Drug Advocacy Program will proactively contact you to complete the enrollment process and gather any additional information required to help you maximize your benefit for Specialty Drugs under the Plan.
Some alternate funding programs require verification of income as a condition of meeting alternate funding program criteria. In such cases, you will be asked to provide this information directly to the advocacy firm or alternate funding program, and such information will not be provided to the Plan.
If you are NOT eligible for an identified alternate funding program, your Specialty Healthcare Case Coordinator will automatically submit your case for benefit reconsideration under the Plan’s appeal process.
Should your claim meet Plan reconsideration criteria, your out-of-pocket costs will be adjusted to the appropriate co-insurance and other cost-sharing amounts of your applicable Plan option, as shown in the Schedule of Benefits tables in the SPD. Your out-of-pocket costs will never exceed those shown in the Schedule of Benefits tables in the SPD if an appeal is approved.
All Specialty Drug prescriptions paid for by the Plan through benefit reconsideration must be dispensed by EmpiRx Health – who will collect your co-insurance and any other cost-sharing amounts as shown in your applicable Plan option Schedule of Benefits as detailed in the SPD.
Any financial assistance you receive will not apply to any deductible or calendar year out-of- pocket maximum amounts.
Questions related to the Specialty Pharmacy Program may be made directly to PaydHealth, by calling 1-877-869-7772.
ABOUT PAYDHEALTH
Reducing Specialty Healthcare Costs
Paying for specialty healthcare the old way no longer works for all of us. Savings generated through network contracting and rebate pricing are not trickling down to group health plans and their beneficiaries. paydhealth is changing the funding of specialty healthcare to re-imagine the possibilities of bringing real savings to the purchaser of healthcare — you.
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