Read Microsoft Word - Drugs Requiring Authorization 4.11.12 FINAL UPDATE text version

Drugs requiring prior authorization

When certain medications require prior authorization

Medco manages the prescription drug benefit for Montgomery County. Under your plan, Medco is required to review prescriptions for certain medications with your doctor before they can be covered. There are Coverage Management programs under your plan: Prior Authorization, Quantity Management and Step Therapy. These are in place to avoid uncovered costs and help Montgomery County to continue providing affordable healthcare options.

Confirm whether your medication requires prior authorization

Review the list of medications in this document. If you or a covered member in your family is taking one of those medications, a "coverage review" may be necessary. If it is, your doctor must obtain prior authorization from Medco so that your prescription can be covered.

Coverage management programs

Below is a list of each of the coverage management programs, with a list of medications that will need to be reviewed by Medco in order for them to be covered by your plan. Prior authorization. Some medications require that you obtain approval through a coverage review before the medication can be covered under your plan. The coverage review process for prior authorization will allow Medco to obtain more information about your treatment (information that is not available on your original prescription) in determining whether a given medication qualifies for coverage under your plan. Those medications include: Androgens and anabolic steroids (Striant®, Testim®, Androgel®, Testoderm®, Anadrol-50®, Oxandrin®, etc.) Dermatologicals (Retin-A®, Avita ®, Tazorac®, Tretin-X® and co-brands, all dosage forms for ages 36 and over) Growth hormones (Genotropin®, Geref®, Humatrope®, Norditropin®, Nutropin AQ®, Serostim®, Saizen®, Zorbtive®, Increlex®, etc.) Quantity management. To promote safe and effective drug therapy, certain covered medications may have quantity restrictions. These quantity restrictions are based on product labeling or clinical guidelines and are subject to periodic review and change. Examples include anti-migraine drugs, rheumatoid arthritis and osteoarthritis drugs, impotence drugs, sleep aids, and pain management drugs. These medications include: Anti-influenza agents (Relenza®, Tamiflu®) Migraine agents (Amerge®, Axert®, Frova®, Imitrex®, Maxalt®, Migranal® NS , Relpax®, SumavelTM, DoseProTM, Treximet®, Zomig®) Smoking deterrents (Chantix®, Nicotrol® NS, Zyban®, etc.)

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Step Therapy The medications listed in the first column below will only be covered by your plan if you get prior approval through a coverage review. If you fill a prescription for one of the medications in the first column without getting prior approval, you'll be responsible for the drug's entire cost. In the third column are medications that can treat the same condition as those in the first column and are preferred by your plan. You can fill prescriptions for these medications without a coverage review, and you'll pay the appropriate co-payment. Ask your doctor whether one of the preferred alternatives would be right for you.

Medication for which you need a coverage review Category Preferred medications you can get WITHOUT a coverage review

Actonel, Actonel with Calcium Alsuma Atacand, Atacand HCT, Avalide, Avapro Atelvia Axert Beconase AQ Benicar, Benicar HCT Edluar Frova Lunesta Maxalt, Maxalt MLT Nasacort AQ, Omnaris Rhinocort Aqua

Osteoporosis (bisphosphonates) Migraine (triptans) Hypertension (ARBs) Osteoporosis (bisphosphonates) Migraine (triptans) Allergy (intranasal steroids) Hypertension (ARBs) Sleep medications (hypnotics) Migraines (triptans) Sleep medications (hypnotics) Migraine (triptans) Allergy (intranasal steroids) Allergy (intranasal steroids)

alendronate, Boniva, Fosamax D

naratriptan, sumatriptan, Maxalt, Maxalt MLT, Relpax

losartan, losartan HCTZ, Diovan, Diovan HCT, Micardis, Micardis HCT

alendronate, Boniva, Fosamax D naratriptan, sumatriptan, Maxalt, Maxalt MLT, Relpax

flunisolide, fluticasone, Nasonex losartan, losartan HCTZ, Diovan, Diovan HCT, Micardis, Micardis HCT Generic drugs, including temazepam, zolpidem naratriptan, sumatriptan, Maxalt, Maxalt MLT, Relpax Generic drugs, including temazepam, zolpidem naratriptan, sumatriptan, Maxalt, Maxalt MLT, Relpax flunisolide, fluticasone, Nasonex flunisolide, fluticasone, Nasonex

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continued... Medication for which you need a coverage review Category Preferred medications you can get WITHOUT a coverage review

Rozerem, Silenor Sumavel Teveten, Teveten HCT Treximet Veramyst Zolpimist Zomig, Zomig ZMT

Sleep medications (hypnotics) Migraine (triptans) Hypertension (ARBs) Migraine (triptans) Allergy (intranasal steroids) Sleep medications (hypnotics) Migraine (triptans)

Generic drugs, including temazepam, zolpidem naratriptan, sumatriptan, Maxalt, Maxalt MLT, Relpax losartan, losartan HCTZ, Diovan, Diovan HCT, Micardis, Micardis HCT naratriptan, sumatriptan, Maxalt, Maxalt MLT, Relpax flunisolide, fluticasone, Nasonex Generic drugs, including temazepam, zolpidem naratriptan, sumatriptan, Maxalt, Maxalt MLT, Relpax

If your doctor believes that you should use a medication that is not preferred, you or your doctor can request a review for coverage. Your doctor can call toll-free 1 800 417-1764, 8:00 a.m. to 9:00 p.m., eastern time, Monday through Friday. If you obtain approval before filling your prescription, you will pay your applicable co-payment. If you obtain approval after filling your prescription, you will be reimbursed the covered cost of the medication minus the co-payment.

If a coverage review is required

To arrange a review, ask your doctor to call Medco toll-free at 1 800 753-2851, 8:00 a.m. to 9:00 p.m., Eastern time, Monday through Friday. If prior authorization is not obtained, you will be responsible for the full cost of the medication at retail. If you mail in the prescription to the Medco Pharmacy, your prescription will be returned unfilled. If coverage is approved, you will pay your normal copayment or coinsurance for the medication. If you have any questions, please call Member Services toll-free at 1 877 796-9758.

The process to determine if prior authorization is required

To save you time and help avoid any confusion, you can check to see if your medication does require prior authorization (coverage review) per the aforementioned list, OR you can call Medco Member Services at 1 877 796-9758. Below, we'd like to highlight the coverage review process, both for retail and mail-order prescriptions.

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continued... At a participating retail pharmacy

You can check yourself to see if your medication requires a coverage review prior to filling your prescription. Or, you can take your new prescription to your local pharmacist, who will submit the information to Medco on your behalf. If a coverage review is necessary, Medco will automatically notify the pharmacist, who in turn will tell you that the prescription needs to be reviewed for prior authorization. As an enrolled member, you or your doctor may start the review process by calling Medco toll-free at 1 800 753-2851, 8:00 a.m. to 9:00 p.m., Eastern time, Monday through Friday. Your doctor will contact Medco and provide further details. After receiving the necessary information, Medco will notify you and the doctor (usually within 2 business days) to confirm whether or not coverage has been authorized. If coverage is authorized, you will pay your normal copayment or coinsurance for the medication. If coverage is not authorized, you will be responsible for the full cost of the medication. If appropriate, you can talk to your doctor about alternatives that may be covered. (You have the right to appeal the decision. Information about the appeal process will be included in the letter that you receive.) You can check yourself to see if your medication requires a coverage review prior to filling your prescription. Or, you can mail the prescription to Medco. If a coverage review is necessary to obtain coverage for the medication, Medco contacts your doctor, requesting more information than appears on the prescription. After receiving the necessary information, Medco notifies you and the doctor (usually within 1 to 2 business days), confirming whether or not coverage has been approved. If coverage is authorized, you will receive your medication and simply pay your normal copayment or coinsurance for the medication. If coverage is not authorized, Medco will send you notification in the mail, along with your original prescription if it was mailed to the Medco Pharmacy. You have the right to appeal the decision. Information about the appeal process will be included in the letter that you receive.

Through your mail-order service, the Medco Pharmacy

Special note: If your medication is subject to quantity management rules, you can obtain your medication up to the quantity allowed. If the prescription exceeds the limit allowed, Medco will alert the pharmacist as to whether a coverage review is needed for the additional amount.

Note: The information outlined above is accurate as of September 1, 2010; however, it is subject to change. Please call Member Services at 1 877 796-9758 if you have any questions or for further verification. All rights in the product names of all third-party products appearing here, whether or not appearing in italics or with a trademark symbol, belong exclusively to their respective owners. © 2010 Medco Health Solutions, Inc. All rights reserved.

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