Pharmacy Benefit Protocols

Transcription

1 Prescription Drug Formularies The AARP MedicareComplete, Evercare, SecureHorizons MedicareComplete, SecureHorizons MedicareDirect SM and UnitedHealthcare MedicareDirect SM Prescription Drug Formularies are the list of drugs that are covered as a pharmacy plan benefit for SecureHorizons and Evercare members. The Formularies contain over 2400 drugs and drug dosage forms. The medications are categorized into four tiers: Lowest Copay (Tier 1), Medium Copay (Tier 2), Highest Copay (Tier 3) and specialty or biological drugs (Tier 4). The member is responsible for the applicable drug copayment or coinsurance. You can access the Prescription Drug Formularies online through one of the following Web sites: n AARPMedicareComplete.com n SecureHorizons.com n UnitedHealthcareOnline.com n EvercareHealthPlans.com n AARPMedicarePlans.com Exceptions Process Formulary Exceptions The Prescription Drug Formularies contain many commonly prescribed drugs. During the course of a plan member s medical care, there may be instances when a member requires a non-formulary drug or a drug that has formulary limits or restrictions (e.g., step-therapy requirements, prior authorization, or quantity limits). SecureHorizons/Evercare may approve an exception request for a nonformulary drug or a drug that has formulary limits or restrictions when medically necessary. To determine medical necessity, the Plan will verify through the physician s supporting statement(s) and/or standards documented in clinical guidelines adopted by the Plan, that 1) the patient has tried and failed and/or has documented contraindications or intolerance to the equivalent formulary medications and 2) no other formulary agent is appropriate to treat the patient s condition. Exception requests will be processed through Prescription Solutions Prior Authorization Department (see Prior Authorization). Tiered Cost Sharing Exceptions In certain circumstances, a member may request a reduction in the copayment or coinsurance amount for a drug on the formulary. If a member is prescribed a Tier 3 drug, the member may request to pay the Tier 2 copayment instead of the higher Tier 3 copayment. Tier 1, Tier 2 and Tier 4 drugs are not eligible for cost-share reductions. A member must meet appropriate medical necessity criteria before tiered cost sharing exceptions will be approved. To determine medical necessity, the Plan will verify, through the physician s supporting statement(s) and/or standards documented in clinical guidelines adopted by the Plan, that all drugs in the lower preferred tiers 1) would not be as effective for the member as the requested drug, 2) would have adverse effects for the member, or both. Tiered cost sharing exception requests will be processed through Prescription Solutions Prior Authorization Review Process (see Prior Authorization). Prior Authorization Prescription Solutions will process coverage determinations and exception requests in accordance with Medicare Part D regulations. Requests will be

2 handled through the Prior Authorization Review Process. Prior authorization requires a drug to be pre-approved in order for it to be covered under a benefit Plan. The Prior Authorization staff will adhere to Plan approved criteria, National Pharmacy and Therapeutics clinical guidelines, and other professionally recognized standards in reviewing each case, rendering a decision based on established protocols and guidelines. Providers can submit prior authorization requests by phone, fax, or online. Providers will be required to submit pertinent medical/drug history, prior treatment history, and any other necessary supporting clinical information with the request. Standard requests will be reviewed and determinations will be made in 72 hours. Expedited or urgent requests will be reviewed and determinations will be made in 24 hours. A request is considered urgent if the requestor believes that applying the standard process may seriously jeopardize the member s life, health, or ability to regain maximum function. Providers will be notified by fax or in writing of the determination. Prescribers or their designated agents may request authorization by one of the following mechanisms: n Toll-free phone number: (800) ; n Written request via fax: (800) for oral medications and (800) for injectable/specialty medications See Appendix 1 for Prior Authorization form n Through our secure Web site, PrescriptionSolutions.com, select the Healthcare Professionals icon. Enter the patient and physician information, select add medication and complete the required fields. Prescription Solutions will contact the physician to validate the prior authorization request. This can be utilized for both oral and injectable medications. Grandfathering Policy Members of SecureHorizons/Evercare health plans in 2009 who received an exception or coverage determination for any of the following reasons will be grandfathered for the 2010 benefit year. n Formulary exception n Quantity Limit exception n Step Therapy exception n Tier exception n Prior Authorization approval n Medicare Part B versus Part D coverage determination Some medications with new quantity limits or Step Therapy requirements for 2010 will require an exceptions review in order for the member to continue taking quantities greater than recommended or FDA approved. Members taking drugs that have moved to a higher tier for 2010 will be required to pay the higher tier copayment. Members currently taking a medication that will no longer be covered under Part D in 2010 will be notified that coverage for the drug will end December 31, Transition Policy New and existing SecureHorizons/Evercare members taking a drug that is not on our formulary or taking a drug that is on our formulary but limited by prior authorization, quantity limits or step therapy, will receive a temporary 31-day transition supply (unless the prescription is written for fewer days). Transition supplies are limited to one fill during the first 90 days your patient is a SecureHorizons/Evercare health plan member. During this time, we encourage you to discuss alternate medication options with your patient that are covered under the plan formulary. If you determine the particular drug is medically necessary, you must request a formulary exception. 2

3 If your patient is a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). We will cover more than one refill of these drugs during the first 90 days for a nursing home resident who is a member of our plan. If after the first 90 days of membership in our plan your patient needs a drug that is not on our formulary or is limited by prior authorizations, quantity limits or step therapy, but is past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless the prescription is written for fewer days) while a formulary exception is pursued. Medicare Part B Versus Part D The following list of drugs or drug classes are covered under the Medicare Part B benefit. Some drugs may be covered by Medicare Part B or Part D benefit, depending on how the drug is used and other factors. Claims may be stopped at the pharmacy to determine which Medicare benefit should cover the drug. n Inhalation Durable Medical Equipment (DME) supply drugs (e.g., drugs given via nebulizer, external or implantable pump) n Immunosuppressive Drugs (such as cyclosporine) for members who have received Medicare covered organ transplants n Hemophilia clotting factors n Oral Anti-Cancer Drugs, provided they have the same active ingredients and indications as non-self administered chemotherapy drugs that are covered n Oral Anti-emetic Drugs, given within 48 hours of chemotherapy administration as full therapeutic replacement for intravenous anti-emetic drugs n Pneumococcal vaccine n Hepatitis B vaccine, for members at high or intermediate risk of contracting Hepatitis B n Influenza vaccine n Antigens n Erythropoietin (EPO) for treatment of anemia in chronic renal disease requiring dialysis n Parenteral Nutrition required for a permanent non-functioning digestive tract which does not allow absorption of sufficient nutrients to sustain current weight or sustain life. Permanence is defined as greater than three months n Intravenous Immune Globulin, provided in the home for primary immune deficiency disease n Injectable drugs administered incident to a physician s service; does not include injectables listed on the NHIC Self-Administered Drug List n Injectable medications not included as a Part D covered drug when administered to a member within the first 100 days as a long term or skilled care resident n Separately billed End Stage Renal Disease (ESRD) drugs n Separately billable drugs provided in hospital outpatient departments n Drugs covered as supplies or integral to a procedure n Blood n Drugs furnished as part of a service in various provider settings Vaccines (including administration) Beginning January 1, 2008, SecureHorizons MedicareComplete, AARP MedicareComplete and Evercare Part D plans cover vaccine administration costs associated with Part D covered vaccines in accordance with CMS guidelines. Claims involving vaccines consist of two parts: 1. Vaccine product The medication dispensed from the pharmacy or doctor s office. 2. Administration fee The administration fee is the cost charged by the pharmacy or doctor s office to inject/administer the vaccine. The administration fee will be reimbursed up to $20. The member s TrOOP will be adjusted for administration fees over $20. 3

4 The following chart describes some of the scenarios for a member to obtain the Part D vaccine and administration. Vaccine Obtained at: The Pharmacy Vaccine Administered/ Injected by: The Pharmacy (not possible in all States or at all pharmacies) Member Responsibility: Member pays his or her standard copay for the vaccine including the administration. The pharmacy submits one claim on which the administration fee is added on to the unit cost of the vaccine. Physician s Office Physician s Office Member pays up-front for the entire cost of the vaccine and the administration fee. Member submits a Direct Member Reimbursement form to Prescription Solutions along with a receipt supplied by the physician office.* Member is reimbursed paid amount less the applicable copayment for the vaccine and up to $20 for the administration fee. The member may be responsible for any administration fee greater than $20. Provider may submit a web-based claim through edispense Vaccine Manager (see below). The Pharmacy Physician s Office Member pays his or her applicable copayment at the pharmacy and the full amount charged by the physcian for administering the vaccine. Member submits a Direct Member Reimbursement form to Prescription Solutions for the administration fee along with a receipt supplied by the physician office.* Member is reimbursed up to $20 for the administration fee. The member may be responsible for any administration fee greater than $20. Provider may submit a web-based claim through edispense Vaccine Manager (see below). * Physician receipt should contain drug name, strength and quantity, prescribing physician s name, date filled and member paid expense, listed separately for the vaccine and administration fee. See Appendix 2 for Direct Member Reimbursement Forms. Please note that this does not apply to Medicare eligible members who do not have a Part D benefit through SecureHorizons. 4

5 edispense Vaccine Manager In order to facilitate the billing of vaccine costs and administration fees from a provider s office, UnitedHealthcare has contracted with Dispensing Solutions, Inc. (DSI) to offer the edispense Vaccine Manager. This program consists of a web portal that provides physician offices with real-time claims processing (through UnitedHealthcare s pharmacy benefit manager, Prescription Solutions) for in-office administered vaccines. This new online resource will help alleviate the burdensome process of manual billing and reimbursement for vaccine and vaccine administrative services. edispense also helps beneficiaries minimize up front, out-of-pocket expenditures for vaccines. Enrollment in edispense is available at no cost to you or your patient. Payment for submitted claims will come directly from Dispensing Solutions once a month. Once enrolled, you will be able to: n Verify members eligibility and benefits in real-time n Advise members of their appropriate out-of-pocket expense (copay, coinsurance) at point of service n Submit vaccine claims electronically n Receive reimbursement information in real-time Note: edispense cannot be used to bill the administration and cost of Medicare Part B covered vaccines (e.g., influenza vaccine, pneumococcal vaccine, or Hepatitis B vaccine for at-risk individuals). Enrollment Instructions You or your authorized staff member may enroll at This is a one-time process that can be updated at any time. The following information will be required: n Tax Identification Number (TIN) n National Provider Identifier(s) (NPI) n Medicare ID number n Drug Enforcement Administration (DEA) number n State Medical License number When using the edispense Vaccine Manager to file a Medicare Part D vaccine claim, physicians must accept UnitedHealthcare s payment amount (including member s copayment) as payment in full for the vaccine. For questions on enrollment and claims processing, call Dispensing Solutions customer support center at (866) 522-EDVM (3386). Medication Therapy Management Program (MTMP) SecureHorizons/Evercare MTMP is designed to improve the quality and safety of clinical care provided to members. This program helps to promote optimum therapeutic outcomes through improved medication use by detecting and reducing the risk of adverse drug events, including drug interactions. SecureHorizons/Evercare member participation in the MTMP is voluntary. Members who are eligible for enrollment in the MTMP are: 1. Members who have at least three out of the four chronic disease states listed below: Congestive heart failure (CHF) Hyperlipidemia Hypertension Diabetes Mellitus 2. Members taking eight or more chronic or maintenance drugs 3. Members at risk for high annual drug costs (Annual expenditure of >$3,000 on Part D drugs.) No additional work will be required of health care providers whose patients participate in the MTMP. Prescription Solutions will send patient-specific reports to the physician that identify therapeutic management options when there are potential problems with a prescribed drug regimen, or as opportunities arise for improving medication use. The intent of sharing these reports with physicians is to assist them in caring for their patients. 5

6 Authorizing and Dispensing Injectable/ Infusion Medication SecureHorizons/Evercare members may use Prescription Solutions Specialty Pharmacy or a contracted network retail pharmacy to obtain their Part D self-injectable and injectable/infusion medications covered under the Medicare Part D prescription drug coverage. The physician must submit the following information to request a Part D covered injectable medication for a member: 1. Completed Prior Authorization Form signed by the requesting physician: The requesting physician s signature is required to allow the vendor to accept the document as a legal prescription 2. Supporting documentation, including: A recent history and physical Copies of pertinent laboratory results Copies of consultant reports The prescribing physician should submit the request to Prescription Solutions Specialty Pharmacy by calling (800) , Option 1, or fax directly to (800) Prescription Solutions will notify the physician of the determination within 72 hours for standard requests, and 24 hours for expedited requests. If the request for injectable medication administered by the physician is approved, Prescription Solutions will verify the member s eligibility and contact the physician s office to coordinate delivery of the medication. In the case of self-injectables, Prescription Solutions will contact the member to coordinate delivery of the medication. 6

7 3515 Harbor Blvd. Costa Mesa, CA Phone: Fax: This form cannot be used to request: Medicare non-covered drugs, including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). Biotech or other specialty drugs for which drug-specific forms are required. [See OR [See links to plan websites at Information on this form is protected health information and subject to all privacy and security regulations under HIPAA. Attn: Specialty Pharmacy PO Box San Diego CA Phone: Option 1 FAX: Please include lab values as necessary Medications Tried & Failed: Other Pertinent Clinical Information: : SEE ATTACHED SEE ATTACHED Turn Around Time: Routine (48 hours) Urgent (24 hours) This electronic fax transmission, including any attachments, contains information from Prescription Solutions that may be confidential and/or privileged. The information contained in this facsimile is intended to be for the sole use of the individual(s) or entity named above. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information is strictly prohibited by law and will be vigorously prosecuted. If you have received this electronic fax transmission in error, please notify the sender immediately and destroy all electronic and hard copies of the communication, including attachments. Health Plan/Insurance Name & State (please print) Name (Last Name, First Name, MI) Mailing Address (Number, Street, City, State & Zip Code) Prescribing Physician's Name Write reason here: Filled at pharmacy, and administered at physician's office Filled and administered at pharmacy Filled and administered at physician's office List the VALID 11 digit NDC number (highest to lowest cost) in the box at the right for EACH ingredient used for the compound prescription. For each NDC number, indicate the "metric quantity" expressed in the number of tablets, grams, milliliters, creams, ointments, injectables, etc. Indicate the TOTAL charge (dollar amount) paid by the patient. Receipt(s) must be provided with claim form Member's/Subscriber's Signature X Prescription Label receipt must have the following information clearly legible or reimbursement could be delayed or denied. Pharmacy Name Prescription number and date filled Drug name, strength, and quantity Member paid expense Prescribing physician's name Please mail label receipt(s) and this completed form to: M0011_071107MO01 (12/07) Group/Employer Name Birth Date Valid 11 digit NDC# HIC Number I.D. Number Social Security Number Physician's Telephone Number (If your primary insurance has already paid for the attached prescription, please complete this section.) An Explanation of Benefit from the primary insurance must include the dollar amount paid by the primary insurance. Primary Health Plan/ Insurance Company Name Primary Member/Subscriber's Name (Last Name, First Name, MI) Check below all that apply to the cost of the claim Administration Cost Vaccine Cost I certify that the patient for whom this claim is made is a covered person in this Prescription Drug Program and that the prescription is for the sole use of the named patient. I also certify that the claim(s) being submitted for payment are not eligible for payment under a no-fault automobile or worker's compensation insurance program. I also authorize release of all information pertaining to this claim(s) to the plan administrator, underwriter, sponsored policy holder, and/or employer. Date 2/24/2006 This form cannot be used to request: Medicare non-covered drugs, including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). Biotech or other specialty drugs for which drug-specific forms are required. [See OR [See links to plan websites at Information on this form is protected health information and subject to all privacy and security regulations under HIPAA. Pharmacy Benefit Protocols Appendixes Appendix 1: Prior Authorization Form AARP MedicareComplete Evercare Medicare Part D Coverage Determination Request Form Prescriber Information Patient Name: Prescriber Name: Member ID#: NPI#: City: State: City: State: Home Phone: Zip: Office Phone #: Office Fax #: Zip: Sex (circle): M F DOB: Contact Person: Diagnosis and Medical Information New Prescription OR Expected Length of Therapy: Qty: Date Therapy Initiated: Height/Weight: Drug Allergies: Diagnosis: Prescriber s Signature: Date: Rationale for Exception Request or Prior Authorization FORM CANNOT BE PROCESSED WITHOUT REQUIRED EXPLANATION Alternate drug(s) contraindicated or previously tried, but with adverse outcome (eg, toxicity, allergy, or therapeutic failure) Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s); Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change Specify below: Anticipated significant adverse clinical outcome Medical need for different dosage form and/or higher dosage Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason Request for formulary tier exception Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome Other: Explain below REQUIRED EXPLANATION: Request for Expedited Review REQUEST FOR EXPEDITED REVIEW [24 HOURS] BY CHECKING THIS BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER S ABILITY TO REGAIN MAXIMUM FUNCTION Click for printable form 3515 Harbor Blvd. Costa Mesa, CA Phone: Fax: Medicare Part D Coverage Determination Request Form Prescriber Information Patient Name: Prescriber Name: Member ID#: NPI#: City: State: City: State: Home Phone: Zip: Office Phone #: Office Fax #: Zip: Sex (circle): M F DOB: Contact Person: Diagnosis and Medical Information? New Prescription OR Expected Length of Therapy: Qty: Date Therapy Initiated: Height/Weight: Drug Allergies: Diagnosis: Prescriber's Signature: Rationale for Exception Request or Prior Authorization FORM CANNOT BE PROCESSED WITHOUT REQUIRED EXPLANATION? Alternate drug(s) contraindicated or previously tried, but with adverse outcome (eg, toxicity, allergy, or therapeutic failure) Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s);? Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change Specify below: Anticipated significant adverse clinical outcome? Medical need for different dosage form and/or higher dosage Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason? Request for formulary tier exception Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome? Other: Explain below REQUIRED EXPLANATION: Click for printable form Date: Request for Expedited Review? REQUEST FOR EXPEDITED REVIEW [24 HOURS] BY CHECKING THIS BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER'S ABILITY TO REGAIN MAXIMUM FUNCTION Appendix 2: Specialty Pharmacy Prior Authorization Form All Plans AUTHORIZATION FORM Patient Name: Physician Information Primary Care MD: Member ID#: Prescribing MD: DEA #: Specialty: City: State: Zip: City: Home Phone: State: Zip: Sex: DOB: Office Office #: Age: Phone #: Fax Height/Weight: Allergies: Contact Person: (one per request form) Length of Therapy: Qty: Refills: Date of Initiation: Diagnosis: ICD: Please send ALL supplies needed for self-administration of medication. Physician Signature: For Internal Use Only Date/Time: Phone Rx R.Ph Rx Attached Clinical History & Physical Findings Delivery Information Date Needed Patient Physician Office Other (specify) MD Will Supply Click for printable form Appendix 3: Direct Member Reimbursement Form AARP MedicareComplete, SecureHorizons MedicareDirect, Evercare MAPD Prescription Drug Program Direct Member Reimbursement Form Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement. Submit this form with the original prescription label receipt(s) within 90 days. Cash register and credit card receipts alone are not acceptable as proof of purchase. Reimbursement is not guaranteed. Claims will be reviewed, subject to limitations, exclusions and other provisions of the Plan Benefit. (one form per patient) Special Instructions: Reason For Request Coordination of Benefits Vaccine and Vaccine Administration Compound Prescriptions Only (Pharmacist signature required) Rx# Date Filled Days' Supply Total Quantity Signature of Pharmacist X Total Charge The claim(s) will be returned if the member/subscriber's signature is not present. Prescription Solutions P.O. Box Hot Springs, AR Reimbursement and correspondence will be issued to the primary member/subscriber. Quantity Click for printable form 7

8 3515 Harbor Blvd. Costa Mesa, CA Phone: Fax: Medicare Part D Coverage Determination Request Form This form cannot be used to request: Medicare non-covered drugs, including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). Biotech or other specialty drugs for which drug-specific forms are required. [See OR [See links to plan websites at Patient Name: Member ID#: NPI#: Prescriber Information Prescriber Name: City: State: City: State: Home Phone: Zip: Office Phone #: Office Fax #: Zip: Sex (circle): M F DOB: Contact Person: Diagnosis and Medical Information New Prescription OR Expected Length of Therapy: Qty: Date Therapy Initiated: Height/Weight: Drug Allergies: Diagnosis: Prescriber s Signature: Date: Rationale for Exception Request or Prior Authorization FORM CANNOT BE PROCESSED WITHOUT REQUIRED EXPLANATION Alternate drug(s) contraindicated or previously tried, but with adverse outcome (eg, toxicity, allergy, or therapeutic failure) Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s); Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change Specify below: Anticipated significant adverse clinical outcome Medical need for different dosage form and/or higher dosage Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason Request for formulary tier exception Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome Other: Explain below REQUIRED EXPLANATION: Request for Expedited Review REQUEST FOR EXPEDITED REVIEW [24 HOURS] BY CHECKING THIS BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER S ABILITY TO REGAIN MAXIMUM FUNCTION Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.

9 3515 Harbor Blvd. Costa Mesa, CA Phone: Fax: Medicare Part D Coverage Determination Request Form This form cannot be used to request: Medicare non-covered drugs, including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). Biotech or other specialty drugs for which drug-specific forms are required. [See OR [See links to plan websites at Prescriber Information Patient Name: Prescriber Name: Member ID#: NPI#: City: State: City: State: Home Phone: Zip: Office Phone #: Office Fax #: Zip: Sex (circle): M F DOB: Contact Person: Diagnosis and Medical Information? New Prescription OR Expected Length of Therapy: Qty: Date Therapy Initiated: Height/Weight: Drug Allergies: Diagnosis: Prescriber's Signature: Date: Rationale for Exception Request or Prior Authorization FORM CANNOT BE PROCESSED WITHOUT REQUIRED EXPLANATION? Alternate drug(s) contraindicated or previously tried, but with adverse outcome (eg, toxicity, allergy, or therapeutic failure) Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s);? Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change Specify below: Anticipated significant adverse clinical outcome? Medical need for different dosage form and/or higher dosage Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason? Request for formulary tier exception Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome? Other: Explain below REQUIRED EXPLANATION: Request for Expedited Review? REQUEST FOR EXPEDITED REVIEW [24 HOURS] BY CHECKING THIS BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER'S ABILITY TO REGAIN MAXIMUM FUNCTION Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.

10 AUTHORIZATION FORM Attn: Specialty Pharmacy PO Box San Diego CA Phone: Option 1 FAX: Patient Name: Turn Around Time: Routine (48 hours) Urgent (24 hours) Physician Information Primary Care MD: Member ID#: Prescribing MD: DEA #: Specialty: City: State: Zip: Home Phone: City: State: Zip: Sex: DOB: Age: Office Phone #: Office Fax #: Height/Weight: Allergies: Contact Person: (one per request form) Length of Therapy: Qty: Refills: Date of Initiation: Diagnosis: ICD: Please send ALL supplies needed for self-administration of medication. Physician Signature: For Internal Use Only Date/Time: Phone Rx R.Ph Rx Attached Clinical History & Physical Findings Please include lab values as necessary Medications Tried & Failed: SEE ATTACHED Other Pertinent Clinical Information: : SEE ATTACHED Delivery Information Date Needed Patient Physician Office Other (specify) MD Will Supply This electronic fax transmission, including any attachments, contains information from Prescription Solutions that may be confidential and/or privileged. The information contained in this facsimile is intended to be for the sole use of the individual(s) or entity named above. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information is strictly prohibited by law and will be vigorously prosecuted. If you have received this electronic fax transmission in error, please notify the sender immediately and destroy all electronic and hard copies of the communication, including attachments. 2/24/2006

11 MAPD Prescription Drug Program Direct Member Reimbursement Form Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement. Submit this form with the original prescription label receipt(s) within 90 days. Cash register and credit card receipts alone are not acceptable as proof of purchase. Reimbursement is not guaranteed. Claims will be reviewed, subject to limitations, exclusions and other provisions of the Plan Benefit. (one form per patient) Health Plan/Insurance Name & State (please print) Group/Employer Name HIC Number Name (Last Name, First Name, MI) Mailing Address (Number, Street, City, State & Zip Code) Prescribing Physician's Name Birth Date I.D. Number Social Security Number Physician's Telephone Number Reason For Request Write reason here: Coordination of Benefits (If your primary insurance has already paid for the attached prescription, please complete this section.) An Explanation of Benefit from the primary insurance must include the dollar amount paid by the primary insurance. Primary Health Plan/ Insurance Company Name Primary Member/Subscriber's Name (Last Name, First Name, MI) Vaccine and Vaccine Administration Filled at pharmacy, and administered at physician's office Check below all that apply to the cost of the claim Filled and administered at pharmacy Administration Cost Filled and administered at physician's office Vaccine Cost Compound Prescriptions Only (Pharmacist signature required) List the VALID 11 digit NDC number (highest to lowest cost) in the box at the right for EACH ingredient used for the compound prescription. For each NDC number, indicate the "metric quantity" expressed in the number of tablets, grams, milliliters, creams, ointments, injectables, etc. Indicate the TOTAL charge (dollar amount) paid by the patient. Receipt(s) must be provided with claim form Rx# Date Filled Days' Supply Valid 11 digit NDC# Quantity Total Quantity Signature of Pharmacist X Total Charge I certify that the patient for whom this claim is made is a covered person in this Prescription Drug Program and that the prescription is for the sole use of the named patient. I also certify that the claim(s) being submitted for payment are not eligible for payment under a no-fault automobile or worker's compensation insurance program. I also authorize release of all information pertaining to this claim(s) to the plan administrator, underwriter, sponsored policy holder, and/or employer. Member's/Subscriber's Signature X Date Special Instructions: Prescription Label receipt must have the following information clearly legible or reimbursement could be delayed or denied. Pharmacy Name Prescription number and date filled Drug name, strength, and quantity Member paid expense Prescribing physician's name The claim(s) will be returned if the member/subscriber's signature is not present. Please mail label receipt(s) and this completed form to: Prescription Solutions P.O. Box Hot Springs, AR Reimbursement and correspondence will be issued to the primary member/subscriber. M0011_071107MO01 (12/07)