Frequently Asked Questions about the Formulary Drug
Benefit
What is a Formulary?
How are Drugs Selected?
How will changes to the Formulary be communicated to
members?
What if the member is out of the area? Where can the
member find a participating pharmacy?
What about Non-Formulary Medication Requests?
What is Prior Authorization?
How do physicians obtain prior authorization?
What if the medication the physician requested is
denied?
What is Step Therapy?
What are my rights regarding coverage decisions, appeals and exceptions?
What is a Formulary?
A Formulary is simply a preferred list of the quality, cost-effective
medications that can be prescribed by physicians and are covered under the
prescription drug benefit. Using a formulary helps us keep premiums as low as
possible by controlling the rising cost of prescription drugs.
The Four Tier Formulary Guide should be taken to the physician’s
office with each visit. This will help your physician to prescribe generic and
brand name medications that are currently on our Formulary (1st and 2nd tier
copay levels). It also identifies drugs for which the physician will need to
obtain prior approval before prescribing.
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How is it decided which drugs to include on the
Formulary?
The Pharmacy and Therapeutics (P & T) Committee makes
recommendations on changes to the Formulary. This committee includes primary
care and specialty physicians, pharmacists and other health care professionals
from our local community. The committee looks first for medications that are
clinically effective. When two or more drugs work equally well, other factors
such as cost and availability are considered. It’s important to note that
all drugs must undergo rigorous testing by the Food and Drug Administration
(FDA) before they will even be considered for the Formulary.
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If a particular drug is not currently a part of the
Formulary, could it be in the future?
Yes, the Formulary is constantly re-evaluated as new medical information
becomes available.
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If a medication is taken off the Formulary can the
drug still be obtained?
Yes, medications that are currently not on the Formulary will be
covered at the third tier copay of your benefit. The member will be responsible
for making the higher copayment for a non-Formulary medication. You may want to
discuss with your physician alternative medications that are on the Formulary
(1st tier and 2nd tier copay) that may be equally effective in treating your
condition.
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How will changes to the Formulary be communicated to
members?
Changes to the Formulary will be published in the member newsletter.
Please remember any changes in medication should be discussed with your
physician.
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What if the member is out of the area? Where can the
member find a participating pharmacy?
The member may call Medco Member Services at 1-800-297-7126 to locate a participating pharmacy in the area where they are.
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How are drugs selected?
Decisions about which drugs to include on the Formulary are made by our
Pharmacy and Therapeutics (P&T) committee, which is comprised of primary
care and specialty physicians, pharmacists and other healthcare professionals
from our community. The committee looks first for medications that are
clinically effective. When two or more drugs work equally well, then other
factors such as cost and availability are considered. If a less expensive drug
does not work equally as well, it will not be included on the Formulary. It's
important to note that all drugs must undergo rigorous testing by the Food and
Drug Administration (FDA) before they will even be considered for the
Formulary.
The Formulary is constantly re-evaluated as new scientific literature
supporting safe and effective use of medications is documented. This means that
a drug that does not appear on the Formulary may be included in the future.
Similarly, a drug that is currently listed may be removed or replaced in the
future.
When your doctor prescribes a drug, be sure to ask him or her whether
it is on the Formulary. Because the Formulary is updated regularly, he or she
will have the latest information.
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What about Non-Formulary Medication Requests?
Sometimes, your doctor may feel it is necessary for you to have a
non-Formulary drug. In that case, he or she needs to discuss the matter with us
before you make a trip to the pharmacy. The doctor can do that by simply faxing
a request with pertinent information to us. We will review the information and
make a decision promptly. If the request is not approved, you will receive a
letter explaining the denial along with information about your right to file a
grievance.
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What is Prior Authorization?
Prior authorization means that certain medications are subject to
pre-approval to be eligible for coverage under your pharmacy benefit. We review
medical information provided by physicians to determine if clinical guidelines
have been met and that the medication is being used appropriately. In addition
to those drugs noted on the Formulary as requiring prior authorization, most
injectable products are subject to prior authorization.
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How do physicians obtain prior authorization?
Download the Prior Authorization form
Download your EOC for more specific information - See Section 6
Your physician needs to complete and fax a "Prior Authorization Request Form" to us using the fax number on the Prior Authorization Form or mail it to:
| |
Attention: Corporate Pharmacy
257 West Genesee Street
Buffalo NY, 14202 |
We have provided copies of this form to physicians’ offices or one can be obtained by calling our Pharmacy Benefits Service Department at 1-716-885-1784.
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How long does it take to get prior authorization?
Decisions will be made within 3 business days. If, however,
additional medical information is required from the physician to make a
decision, it may take additional time for us to respond to the physician’s
request.
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What if the medication the physician requested is
denied?
When a medication request is denied, alternative treatment options,
which are covered under the benefit, are provided to the physician. Each case
is reviewed individually and decisions are made based on medically sound
clinical criteria developed and/or approved by one of our physician
committees.
- If the prior authorization request for a specific medication is
denied, the drug is considered a non-covered benefit. It is not available as a
third-tier medication.
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What is Step Therapy?
In some cases, patients who take prescription drugs to treat a medical condition may be required to try certain covered drugs first before moving on to other more expensive drugs. Even though some drugs are less costly does not mean they are less effective. If Drug A and Drug B are both used for the same condition, we may require the use of Drug A before the patient moves on to Drug B. If Drug A does not work for the patient, we will then cover Drug B.
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What are my rights regarding coverage decisions, appeals and exceptions?
The following is the process for coverage decisions and making appeals deals with problems related to benefits and coverage for medical services and prescription drugs, including problems related to payment. This is the process to use for issues such as whether something is covered or not and the way in which something is covered. For complete details on your medical and prescription drug coverage please refer to your Evidence of Coverage (EOC). There is a complete section of the EOC devoted to the details of coverage decisions, appeals and exceptions. Learn More»
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