member may be responsible for their copay / coinsurance plus the cost difference between the brand medication and the generic medication ( ancillary charge ). Ancillary charges do not accumulate towards meeting your annual deductible or out-of-pocket maximums .
The formulary applies only to outpatient drugs provided to members , and does not apply to medications used in inpatient settings .
What if my drug is not listed on the formulary ?
To avoid delays in access to your treatment , your provider may check the formulary to prescribe a covered drug that is best for you . The HometownRx formulary offers a wide coverage of available drugs . However , in instances where the drug is rejected due to “ Drug Not Covered ”, you may either :
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Ask your pharmacy to contact your provider to change the prescription to a covered formulary alternative .
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If your provider believes the non-covered product is “ medically necessary ” for your condition , your provider may request an “ Exception ” for coverage . See the next section for information on how to request an exception .
How do I request an exception ?
Members or providers can ask HometownRx to make an exception to our coverage rules . Exceptions are reviewed for medical necessity , your inability to use covered drugs ( e . g ., side effects , contraindications , allergies ), current covered products may not be effective for you , and new drug entrants that have not yet been reviewed and placed on the formulary . Reviews will consider superiority of the request over current covered options .
Exception requests can be submitted by making the request to HometownRx : �
You or your provider can call us at 1-888-807-7655 , or submit a written request for prior authorization review via fax at 1-858-790-7100 .
Why do some drugs require prior authorization ?
Drug coverage review is used to encourage appropriate and cost-effective use of prescription drugs by allowing coverage only when certain conditions are met . Some reasons for pre-authorization may include :
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Compliance with dosing guidelines Avoid duplicate therapies
Help health care providers check medically accepted criteria that helps ensure high efficacy and low side effects
HometownRx implements prior authorization criteria based on the Food and Drug Administration ( FDA ) approved labelling , evidence-based national best-practice guidelines , and peer-reviewed journals .
What can I expect to pay ?
What you expect to pay depends on the type of drugs your provider ordered for you . Each drug is placed in a tier level ; different tiers represent the different levels of payment for covered medications . Tier structures are developed to encourage you to use quality products at the most cost-effective option to you . The lower cost