- Consumers have the right to receive information about Catalyst Rx's Pharmacy Benefit Management (PBM) services, pharmacy network, credentials criteria, formulary, clinical guidelines and its Consumer Rights and Responsibilities.
- Consumers have the right to be treated with respect and dignity and have the right to privacy.
- Consumers have the right to be free to exercise their rights and to be treated fairly based on federal and state laws such as the:
- Age Discrimination Act of 1975
- Civil Rights Act of 1964
- Rehabilitation Act of 1973
- Titles II and III of the Americans with Disabilities Act
- Health Insurance and Portability Act of 1996 (HIPAA)
- Consumers have the right to participate in decision-making regarding their treatment and receive a clear explanation from their pharmacist about prescribed medication regimes.
- Consumers have the right to all covered benefits and to be treated timely by qualified pharmacists who can communicate medication treatment plans.
- Consumers have the right to confidentiality of their treatment records to the extent protected by federal and state laws as well as HIPAA regulations, unless the Consumer signs a release of information. Consumers are also entitled to receive an explanation regarding exceptions to confidentiality.
- Consumers have the right to voice complaints or to appeal to Catalyst Rx on PBM and Prior Authorization services.
- Consumers have the right to be provided, upon request, with information about their plan's benefits and fee structure, including limitations and exclusions to their formulary.
- Consumers have the right to receive translation services from an appropriate, clinically trained translator when contacting the Catalyst Rx Member Services Department or when receiving PBM services such as Prior Authorization or registering a complaint and/or appeal.
- Consumers have the right to make suggestions and give comments on ways Catalyst Rx can improve its policies, procedures and services.
- Consumers have the responsibility to read their insurance certificate for their PBM coverage. If they do not understand the information, they should contact either their insurance company or call the Catalyst Rx Member Services Department so they may understand covered benefits, limitations and authorization procedures.
- Consumers have the responsibility of presenting their member identification card when accessing PBM services.
- Consumers have the responsibility of knowing how to access services from a participating pharmacy.
- Consumers have the responsibility to pay any applicable insurance copayments at the time of service.
- Consumers have the right to receive prompt, competent and courteous service from all Catalyst Rx and network pharmacy personnel. In turn, Consumers have the responsibility to demonstrate mutual respect and courtesy towards pharmacies and Catalyst Rx personnel.
Catalyst Rx Affirmative Statement Concerning Incentives with Utilization Management (UM) Decisions
Catalyst Rx is committed to encouraging appropriate utilization of pharmacy benefit management (PBM) services and the avoidance of underutilization. Underutilization of care and services carries significant risks to the well-being of members such as possible inappropriate and/or delayed treatment, preventable contraction of disease, extended duration and/or exacerbation of symptoms, undetected progression of disease, misdiagnosis, lowered quality of life, permanent loss of function and preventable death.
Practitioners, pharmacies, consultants, committee members and staff who make utilization-related decisions need to exercise special care when performing their responsibilities related to Utilization Management.
Catalyst Rx does not use any incentives to encourage barriers to PBM services by ensuring the following:
- The Catalyst Rx UM decision-making process is based only on the appropriateness of care and service and the existence of coverage.
- Catalyst Rx does not specifically reward practitioners or other individuals for issuing denials of coverage.
- Financial incentives for Catalyst Rx UM decision makers do not encourage decisions that result in underutilization.