WAC Cost Sharing Issuer may not charge an ancillary charge, in addition to the plan's for normal copayment or coinsurance requirements, for a drug that is Substitute covered because of one of the circumstances set forth in either WAC Drugs 284-43-5080 or 284-43-5100. An ancillary charge is any charge in addition to or excess of cost-sharing. Cost Sharing WAC When an enrollee requests a formulary brand name drug in lieu of a for therapeutically equivalent generic drug or a drug from a higher tier, Substitute and there is no clinical basis for the substitution, carrier may require Drugs enrollee to pay the difference in price between the drug that the (Cont’d) formulary would have required, and the covered drug, in addition to the copayment. This charge must reflect the actual cost difference. WAC When carrier approves a substitution drug, whether or not the drug is in the formulary, enrollee's cost-sharing must be adjusted to reflect any discount agreements or other pricing adjustments for the substitution drug available to carrier. Any charge to the enrollee for a substitution drug must not increase carrier's underwriting gain for the plan beyond that calculated for the original formulary drug.
Cost Sharing for Substitute Drugs Cost Sharing for Substitute Drugs (Cont’d) WAC Issuer may not charge an ancillary charge, in addition to the plan's normal copayment or coinsurance requirements, for a drug that is covered because of one of the circumstances set forth in either WAC 284-43-5080 or 284-43-5100. An ancillary charge is any charge in addition to or excess of cost-sharing. WAC When an enrollee requests a formulary brand name drug in lieu of a therapeutically equivalent generic drug or a drug from a higher tier, and there is no clinical basis for the substitution, carrier may require enrollee to pay the difference in price between the drug that the formulary would have required, and the covered drug, in addition to the copayment. This charge must reflect the actual cost difference. WAC When carrier approves a substitution drug, whether or not the drug is in the formulary, enrollee's cost-sharing must be adjusted to reflect any discount agreements or other pricing adjustments for the substitution drug available to carrier. Any charge to the enrollee for a substitution drug must not increase carrier's underwriting gain for the plan beyond that calculated for the original formulary drug.
cklist-forms-18-disability-ind-s-a-dental-w-pediatric-ehbs.docx