name> be covered even though it is not on your plans formulary. They must give a supporting statement that explains that all other drugs on the formulary would have adverse effects (be harmful to you) or be less effective (not work as well). You can also make this request to us. We will then reach out to your doctor to see if they feel this is the only drug that will work for you. Every drug on the Drug List is in one of five (5) Remember to include the Extra Plan Benefits plan’s cost-sharing tiers. In general, the higher the Help paragraph. Drug Tier Questions cost-sharing tier, the higher your cost for the drug: Warning: Remember to check if Tier 1: (Preferred Generic Drugs) Tier 1 is the member is asking for a your lowest-cost Generic tier and includes coverage determination for the preferred generic drugs. Generic drugs brand drug. contain the same active ingredients as brand drugs and are equally safe and effective. Tier 2: (Generic Drugs)This is your higher-cost Generic tier and includes generic drugs and sometimes some preferred brand drugs. Tier 3: (Preferred Brand Drugs) This is your middle-cost tier, and includes preferred brand
name> be covered even though it is not on your plans formulary. They must give a supporting statement that explains that all other drugs on the formulary would have adverse effects (be harmful to you) or be less effective (not work as well). You can also make this request to us. We will then reach out to your doctor to see if they feel this is the only drug that will work for you. Drug Tier Questions Every drug on the plan’s Drug List is in one of five (5) cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug: Tier 1: (Preferred Generic Drugs) Tier 1 is your lowest-cost Generic tier and includes preferred generic drugs. Generic drugs contain the same active ingredients as brand drugs and are equally safe and effective. Tier 2: (Generic Drugs)This is your higher-cost Generic tier and includes generic drugs and sometimes some preferred brand drugs. Tier 3: (Preferred Brand Drugs) This is your middle-cost tier, and includes preferred brand Plan Benefits Remember to include the Extra Help paragraph. Warning: Remember to check if the member is asking for a coverage determination for the brand drug.
ICE_AG_Grievance_Resolution_Matrix___Final(1).docx