Some medications are included on the Medica Part D formularies within certain parameters. Thee most common utilization management parameters in Medica Part D formularies include prior authorization (PA), step-therapy (ST), and quantity level limits (QL). For a Part D prescription to be covered upon dispensing of the drug, the medication order must first satisfy these parameters to be a covered Part D claim.
- A medication is restricted for coverage for certain diagnosis, conditions, or requires monitoring parameters to be me. Prior authorization is required prior to payment of the medication to the pharmacy. Part D drugs that require prior authorization are noted with a PA on the Part D Formulary.
- A coverage determination form should be completed and submitted to Medica prior to filling a prescription at a participating pharmacy (see coverage determinations below).
- Part D Drugs that require prior authorization and the approval criteria are available at Pharmacy Resources. Go to Pharmacy Resources.
- Step Therapy is a program focused on encouraging the use of cost-effective prescription drugs as first line treatment when therapeutically appropriate.
- Generic drugs are typically identified as preferred, or Step 1, treatments. Formulary brand name drugs are considered Step 2 and would be covered for members who have already tried and failed a Step 1 treatment alternative.
- Medications appropriate for Step Therapy are identified based on a thorough review of drug categories where a doctor has many safe, effective treatment options. All Step Therapy programs have been reviewed and approved by Medica’s Pharmacy and Therapeutics Committee, a panel of independent practicing physicians and pharmacists.
- A medication is restricted for coverage under a certain quantity over a given period of time. Quantity level limits could restrict a medication to a certain number of units of a medication for each prescription or for a number of units per day. Part D drugs that require a quantity level limit are noted with a QL on the Part D Formulary.
- Quantity level limits are placed on medications to ensure safe and recognized effective doses are prescribed prior to coverage under Medicare Part D.
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