Prior Authorization/Formulary

Prior Authorization Overview (Step Therapy)
Prior Authorization Number-Rejections
Brand Interchange
Voluntary Formulary Benefit

Prior Authorization Overview

• Prior authorization numbers are specific to the Member's identification number and the code of the Pharmaceutical Service.
• Once the authorization has been granted, MedImpact will enter it into the system and the claim will adjudicate.

A new prior authorization number will be required

• If the Member's identification number changes.
• If the prior authorization number has expired.
• PA numbers for "Vacation Request" and "Refill too Soon" are valid for one time only.

Medical Exception Types
The following reject messages may require authorization before MedImpact will return a paid claim response.

• Prior Authorization Required

Pharmaceutical Service requires prior authorization before it will be covered under a Member's Benefit Contract. The clinical information must be provided by the prescriber.

• NDC Not Covered

Pharmaceutical Service being dispensed is generally not covered by a Member's Benefit Contract, but may be considered for coverage if review is required by law.

• Refill Too Soon

Pharmaceutical Service is being refilled earlier than allowed by a Member's Benefit Contract. Legitimate requests for early refills may be authorized.

• Cost Exceeds Maximum

A claim is being submitted with an ingredient cost greater than $999.99 ($100.00 for compounded prescriptions) as established by Medica. Authorization to dispense the prescribed Pharmaceutical Service can be requested by calling MedImpact.

• MAC Exception

Pharmaceutical Services reimbursed at the generic level may be considered for brand name reimbursement upon appropriate written documentation from the Member's Participating Provider. Pharmacy will be reimbursed at the MAC price level unless a prior authorization number is submitted with the claim.

• Plan Benefit Exceeded
• Pharmaceutical Service being dispensed falls outside the Member's Benefit Contract.
• Quantity Level Limit

The Pharmaceutical Service prescribed may have a maximum quantity level limit based on the Member's Benefit Contract. Information must be provided by prescriber.

• Coverage Limitation

The Pharmaceutical Service prescribed has limited coverage as designated in the Member's Benefit Contract.

• Vacation Request 

The Member's Benefit Contract may allow Pharmacy to request a prior authorization to submit a claim in excess of the Benefit Contract's days' supply

The prior authorization department at MedImpact is available from 8 a.m. to 8 p.m. CST, Monday - Friday. And 8 a.m. to 4:30 p.m. Saturday and Sunday. Pharmacy may contact the Pharmacy "Hotline" at 1-800-788-2949 to request an authorization.

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Prior Authorization Number-Rejections

Prior authorization number rejections correspond to NCPDP Reject Code 37 (Missing/Invalid Authorization Number).

MedImpact's on-line system will reject claims for Pharmaceutical Services submitted with a prior authorization number for the following reasons:

• The authorization has exceeded the duration limit.
• More than one override condition exists for a particular claim, requiring an authorization that will authorize multiple conditions.

Medica Drug Formulary Overview

The Medica Drug Formulary classifies Pharmaceutical Services into the following categories.

• CEQ (Chemically Equivalent)
  A Pharmaceutical Service is chemically equivalent if it contains the same active ingredients, same dosage form, and the same strength.
  
• TEQ (Therapeutically Equivalent)
  A Pharmaceutical Service is therapeutically equivalent if it contains ingredients that produce a similar therapeutic effect, but are not CEQ.

The Member's Benefit Contract may include a Drug Formulary for CEQs and/or TEQs as follows.

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Brand-Brand Interchange

• Requires Mandatory Interchange of CEQ
  Coverage for only Drug Formulary CEQ Pharmaceutical Services. The Participating Provider may have to be contacted to determine whether to substitute the Drug Formulary Pharmaceutical Service.

• Allows Voluntary Interchange of TEQ
  Coverage where the Participating Provider or Member requests a non-formulary TEQ Pharmaceutical Service.

• Mandatory
  A Mandatory formulary allows coverage for Pharmaceutical Services contained on Medica's Drug Formulary only.

• Voluntary
  A Voluntary formulary allows coverage of a non-formulary Pharmaceutical Service when the Participating Provider or Member requests a non-formulary Pharmaceutical Service.

Medica Drug Formulary Benefits
MedImpact has established standardized free-form text messages that are returned to Pharmacy when a non-formulary Pharmaceutical Service has been submitted. This message indicates the Member's formulary benefit.

Mandatory Formulary Benefit
MedImpact will notify Pharmacy with a standard NCPDP claim reject message:

If a non-formulary Pharmaceutical Service is prescribed, Pharmacy is contractually obligated to use their best efforts to contact the Participating Provider to ask if the Pharmaceutical Service may be changed to a formulary product.

If the Participating Provider will not allow a change to the formulary product, or the Member requests that the non-formulary product be dispensed the following applies:

• If the Member's Benefit Contract does not include a non-formulary benefit, the Pharmaceutical Service will not be covered under the Member's Benefit Contract and the Pharmacy should collect Pharmacy's Customary Charge for the non-formulary Pharmaceutical Service.

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Voluntary Formulary Benefit
When the Member's Benefit Contract specifies a voluntary formulary, MedImpact will approve the non-formulary product.

The Member's Benefit Contract may require the Member to pay a higher Copayment, Coinsurance or Deductible for the non-formulary product.