Introduction Overview The Health Plan shall promote optimal therapeutic use of pharmaceuticals by encouraging the use of cost effective generic and/or brand drugs in certain therapeutic classes. The Health Plan has processes in place that explain how members, pharmacists, and physicians: 1. The Health Plan publishes a prescription formulary list annually or more frequently if updates are made. The formulary includes listings of generic drugs that are available for our membership. The formulary also includes listing of drugs (brand or generic) that are preferred for use in certain therapeutic classes. 2. Prescriptions can be filled at any participating THP pharmacy. 3. Where state pharmaceutical dispensing laws permit, the pharmacy is encouraged to dispense generic forms of prescribed drugs. Only generic drugs that are listed in the FDA orange book as being therapeutically equivalent to the innovator product (brand) are required to be dispensed as a generic drug. This is also known as AB rated. 3.1 In therapeutic classes where The Health Plan has preferred drugs for the treatment of certain diseases, only those drugs are to be used. The Health Plan publishes and provides a list of the preferred drugs in those classes. The list is available on The Health Plan website and is provided as a service to our prescribers. In cases where the physician has written for a drug not on the list, the dispensing pharmacist will contact the prescriber to change the medication if possible to the preferred drug in the class. Therapeutic substitution is only permitted with authorization by the prescriber in the form of a new prescription. 3.2 The Health Plan pharmaceutical management program allows consideration of medical necessity exceptions for members in obtaining coverage for non-preferred drugs and brand drugs when a generic is available. Clinical Criteria for Pharmaceutical Management Program The Health Plan pharmaceutical management program utilizes standard criteria to construct the formulary. The clinical criterion used is taken from relevant clinical literature. 1. Quality Criteria: After FDA approval, each drug is reviewed with regard to its: therapeutic indications, efficacy, dosage frequency, adverse events, therapeutic index, potency, and any compliance factors. 2. Cost Analysis: Each drug is reviewed with regard to its cost in comparison to any formulary alternative in its class. If there is no formulary alternative, the drug is placed on the formulary. If the drug under review has a lower cost alternative, continued review is indicated. 3. Quality vs. Cost: Other cost considerations are examined and include a pharmacoeconomic perspective that evaluates drug therapy cost-effectiveness as it relates to physician visits, patient costs, emergency room visits, laboratory costs, hospitalizations, and sick days. 4. Special Considerations: Criteria is in place for prior authorization of identified drugs, education of physicians and members, drug inclusion in clinical guidelines, and placement of quantity limits on drugs dispensed.
5. Clinical literature is used in every decision to add pharmaceuticals to or exclude pharmaceuticals from the formulary. Clinical evidence shall come from appropriate government agencies, medical associations, national commissions, peer-reviewed journals, and authoritative compendia. Supplemental Prescription Services Drug Riders Prescription drugs are an integral component of a comprehensive health maintenance plan. The Health Plan through the efforts and recommendations of medical specialists, family practitioners and pharmacists, has developed this. This group of actively participating providers, known as the pharmacy and therapeutics committee, has evaluated the therapeutic classes of drugs and their costs effectiveness. The results of that evaluation, which was bases on sound clinical evidence, is the creation of a list of drugs (formulary) to allow for the availability of appropriate medications for our members needs. In addition, the formulary allows the prescription costs and premiums to be maintained at affordable levels. The pharmacy and therapeutics committee has further developed policies and procedures to direct the use of the prescriptions within The Health Plan. These policies and procedures are designed to enhance the appropriate use of prescriptions in both a clinical and cost-effective manner.
Obtaining a Prescription Locating a Pharmacy in The Health Plan Network A THP member may obtain a prescription at any participating THP pharmacy. For the location of a participating pharmacy, call our prescription benefit manager at 1.800.988.2262 or www.expressscripts.com. The Health Plan identification (ID) card must be presented to the pharmacist to allow dispensing of the prescription. The member will be required to pay a copayment at the time of service based on the prescription rider plan of the member and will be collected at time of service. The copay variations are printed on the member ID card. Choosing a Preferred Formulary Drug Formulary Tier Definitions Prescription Drugs that can only be dispensed upon order (prescription) by a qualified provider of care. Additionally, only drugs, which are labeled Caution: Federal law prohibits dispensing without a prescription, will be considered eligible. Generic A drug available as a chemically and therapeutically equivalent copy of a brand name drug. It is usually available from several manufacturers. Generics must meet Federal standards for potency and bioavailability. Brand Drug A prescription item only available from a single source supplier. Multi-Source Brand Drugs Brand name drugs which are manufactured by more than one producer. These agents are usually available as Generic equivalents. Over-the-Counter Drugs (OTC) Drugs which are not restricted to prescription only status. These agents are available for purchase without physician approval and are not covered by The Health Plan Home Delivery Service Certain group benefit designs allow members to receive medications at home via the mail. (See your specific benefit rider for details.). Pharmaceutical Substitution and Interchange Program Where state pharmaceutical dispensing laws permit, the pharmacy is encouraged to dispense generic forms of prescribed drugs. Only generic drugs that are listed in the FDA orange book as being therapeutically equivalent to the innovator product (brand) are required to be dispensed as a generic drug. Generic Difference Policy If a prescription order specifies that a brand name drug must be dispensed when the generic equivalent is available, or the prescription order allows for generic substitution and the member elects to have the prescription filled with a brand name drug instead, the member must pay the brand copayment plus the difference between The Health Plan cost of a brand name and its generic equivalent (i.e., The Health Plan only pays for the generic cost.) Please note: Non-formulary brand versions of generic drugs require coverage review.
Formulary Overview of The Health Plan Formulary The Health Plan formulary is a listing of prescription medications that are preferred for use. The Health Plan maintains a restrictive formulary. Formulary drugs will be a covered benefit when dispensed at participating pharmacies. Drugs not listed are not covered without written medical statements of necessity by the prescribing physician. Statements of medical necessity are subject to review and approval by The Health Plan medical director and when necessary, the pharmacy and therapeutics committee. Standard requests for coverage determinations will be processed within 72 hours. Requests for non-urgent coverage determinations received after 5pm will be processed the next business day. Urgent requests for coverage determinations will be processed within 24 hours. Multi-source drugs must be dispensed as the generic. Failure to dispense the generic will subject the member to a higher copayment. This higher co-pay consists of the brand copayment plus the cost difference of the brand drug and generic drug. Exclusions and Limitations The following will not be covered or paid for by The Health Plan: 1. The charge for any prescription refill other than the number set by the prescriber. Additionally, no refills dispensed more than one year from the date of the original prescription. 2. The charge for any prescription, oral, or topical that is prescribed for cosmetic purposes. 3. The charge for any medications not FDA approved for use in the general population. Additionally, the use of an FDA approved drug in the treatment of a non-fda approved indication will not be covered. 4. The charge for an eligible drug not prescribed by a THP qualified provider, except in an emergency. 5. The charge for any medication covered by a workers compensation or occupational disease laws, any other group policy, or government program which is not The Health Plan s program. 6. Vitamins, except for prenatal are not covered. Prenatal vitamins covered when related to a pregnancy only. 7. Dental related prescriptions such as, but not limited to, oral fluorides, dental mouthwashes, devices used in dental therapy. 8. Prescriptions related to smoking cessation. Your prescription benefit may provide coverage of some smoking cessation products as preventative medications. Coverage of these products may be limited to certain formulary drugs as determined by The Health Plan. 9. Prescriptions for drugs or devices used to promote weight loss. 10. Prescriptions used to treat sexual dysfunction, either oral or topical, or devices used for impotence. 11. Appliances and therapeutic devices that may require a prescription are not covered. These include, but are not limited to garments, splints, bandages, or braces regardless of intended use. 12. Laxatives are not covered. Insurance Fraud Warning: Pursuant to Ohio Revised Code Section 3999.21, Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Non-Formulary Requests (Exception Policy) Certain non-formulary medications are eligible for coverage only after a patient-specific approval has been authorized. Patient-specific criteria may include age, gender, and clinical conditions determined by the physician for authorization to be granted for a specific drug. You or your physician may contact The Health Plan for information on specific drugs and the procedures for authorization. Should the prescribing physician determine the original (non-formulary) drug is medically necessary, then the member or physician should contact The Health Plan to initiate an authorization request at 1.800.624.6961 extension 7914. Standard requests will be processed within 72 hours. Urgent requests will be processed within 24 hours. The Health Plan Pharmacy Service Department is available Monday through Friday, 8 a.m. to 5 p.m. and after hours via telephonic auto attendant s emergency option seven days a week, including holidays. They may be reached at 1.800.624.6961, ext. 7914; fax 304.885.7592. Requests will be reviewed according to the following criteria: 1. The request for the non-formulary drug is for a condition or medical need not met by existing drugs on The Health Plan formulary. 2. In the physician s medical judgment, the formulary alternatives have been ineffective in the treatment of the member s disease or condition (documentation in the member s clinical record required.) 3. The formulary alternative causes, or is reasonably expected by the prescriber to cause, a harmful or adverse reaction in the member (documentation in the member s clinical record required.) Pharmacist deems dispensing emergency situation: In cases of an emergency, when the prescribing physician and/or The Health Plan cannot be reached, a 72-hour supply of the non-formulary medication can be filled if necessary. The member will be responsible for the costs; however, they should submit the receipt to The Health Plan for reimbursement. Provided the prescription meets the coverage guidelines as further specified in this document, the member will be reimbursed according to the plan. The non-formulary prescription must be converted to a formulary prescription unless medical necessity is proven for the use of the nonformulary prescription. Authorization for Coverage Authorization for coverage consists of rules-based programs for determining whether members qualify for coverage of a requested drug based upon the plan s predefined benefit criteria. Predefined benefit criteria are based on recommendations of a P&T committee. These rules are periodically reviewed for appropriateness. Mandatory Generic Policy and Formulary Override Procedure Mandatory Generic Drug Riders Review for Exemption Policy: Drug riders with a mandatory generic component require: If the prescription item ordered is available from a generic supplier, The Health Plan will cover the maximum allowable cost of the generic. Any additional costs of brand name medication will be the responsibility of the member. This is regardless of any dispense as written indicators (DAW).
Exemption Review Request Procedure: At the time of dispensing, the pharmacist will transmit a claim to The Health Plan claims processor. If the item submitted is available as a generic, the claims processor returns the cost of the prescription to the following manner: Brand submitted: The brand copay is assessed + the difference in the cost of the generic and brand product to arrive at a brand penalty copayment. Copay = brand copayment + penalty Generic submitted: The generic copayment is assessed and it is the member s responsibility to pay at the time of dispensing Exemptions The following agents are exempt from mandatory criteria: Generic drugs not listed in the FDA orange book of generic equivalents with an AB rating. AB rating is defined as therapeutic and generic equivalent. In cases of defined medical necessity, an exemption to the mandatory generic policy may be authorized. Exemption requests can be called to pharmacy services at 1.800.624.6961, extension 7914 or faxed to 304.885.7592. The requests must include: Supporting medical literature describing treatment failures of the generics may be required. Defined allergic potential to a specific component in a generic NOT found in the brand product. (i.e., fillers, dyes, preservatives) Documented treatment failure of a specific member with supporting clinical assessment and appropriate lab readings. Member refusal to take the generic is not acceptable.
Prior Authorizations Program Description The Health Plan Pharmacy Services Department handles customer service calls and coverage review determinations as well as eligibility and prior authorization updates. The Health Plan administers two prior authorization programs, a client prior authorization program (CPA), and the traditional managed prior authorization (TPA) Program. Both programs evaluate coverage eligibility before initiation of therapy and throughout the course of therapy by adjudicating coverage to conform to the conditions specified by the member s benefit. Traditional Prior Authorization (TPA) A program where The Health Plan Pharmacy Services department adjudicates coverage review determinations as well as authorization updates. This program criteria are developed and conformed to plan coverage conditions for client review and selection and in administering prior authorization protocols. Traditional prior authorization rules require coverage review for all claims presented, for a given drug, to determine if the member qualifies for coverage for use of the drug, based upon The Health Plans pre-defined benefit criteria. Smart Rules Automated Prior Authorization Processes at the Point of Sale Smart rules use sophisticated logic in conjunction with available medical history, drug history, patient reported health information, and medical claims information to determine whether or not a member qualified for coverage for use of a drug based on the plan s pre-defined benefit criteria. Smart rules and ExpressScripts system capabilities allow coverage management programs to more efficiently qualify for coverage of those claims that are consistent with the benefit. As a result, smart rules limit reviews for coverage to only those claims where the member s request is least likely to be appropriate for coverage. Authorizations for coverage Smart rule capabilities include qualification or disqualification by medical and prescription history. Qualification-by-history logic searches the member s history for the presence of data that will qualify the member for coverage without a requirement for coverage review. Only that member for whom such data is absent requires review for coverage. Disqualification-by-history logic searches the member s history for the presence of date that will disqualify the member for coverage without a requirement for coverage review. Only those members for whom such data is present require review for coverage. Authorizing Amount of Coverage Authorization of amount for coverage is a collection of rules-based programs for determining whether members qualify for coverage of the full amount of drug requested based on the plan s pre-defined benefit criteria. Authorization of amount for coverage programs use smart rule logic to determine if members qualify for coverage for medications beyond drug- specific thresholds for a quantity, dose and/or duration deemed reasonable for most uses. Quantity Per Dispensing Event Quantity per dispensing event rules set dispensing quantity thresholds that reduce client exposure to unnecessary cost, without creating obstacles to access for the vast majority of users. An example is
coverage for Fluconazole in its 150 mg strength. Fluconazole 150 mg is used to treat vaginal yeast infections. A single tablet may represent an entire course of therapy. Under normal circumstances, a member of a plan allowing a 30-day supply at retail could obtain as many as 30 tablets for a single copayment. In contrast, the quantity per copayment rule allows coverage of only one or two tablets, an amount more consistent with the plan s intent for the benefit. In addition, through coverage review, traditional prior authorization, members can be qualified for additional coverage where warranted by special circumstances and consistent with the intent of the benefit. Common Drugs with Quantity Limits Migraine medications Naratriptan 20 mg/23 days Rizatriptan Benzoate 120 mg/23 days Sumatriptan 900 mg/23 days Dihydroergotamine Messylate 8 ampules/23 days; Eletriptan 320 mg/23 days Zolmitriptan 40 mg/23 day Miscellaneous drugs Linezolid 14 tabs/ rolling 30 days Lidocaine 90 patches/23 days