The
standard prescription drug benefit allows up to a 31-consecutive-day supply of medication per prescription copayment, coinsurance or deductible.
Exceptions to this quantity limitation include:
- Insulin up to a 31-day supply per type of insulin per copayment, coinsurance or deductible.
- Diabetic supplies up to a 31-consecutive-day supply or 100 units.
- Ostomy supplies up to a 31-consecutive-day supply.
Some prescription medications require prior authorization, as noted in the drug formulary. When filling a member’s prescription a pharmacist may receive a computer message from MedImpact if the medication requires prior authorization. In those cases, please contact MedImpact at 1-800-820-8482, with pertinent member and clinical information. The physician will be notified of the decision.
Step Therapy is a program focused on encouraging the use of cost-effective rather than less cost-effective drugs. With Step Therapy, certain drugs within a therapeutic class are grouped in a logical series of steps that a provider can follow when treating a patient.
Generic drugs are typically identified as Step 1 drugs. Formulary brand name drugs are considered Step 2 and non-formulary brand drugs would be considered Step 3. In order for the member to get a Step 2 drug they must have tried and failed a Step 1 drug. This series of steps follows current medical guidelines and best practice standards, and this is one of the ways Medica can help clients and members manage the rising cost of healthcare.
Quantity limits identify the maximum quantity of medication that can be dispensed over a specific period of time at the applicable copayment, coinsurance, or deductible. Typically, quantity limits are in place to encourage appropriate drug utilization and contain medication cost. Quantity limits are based on the product’s labeling, or adopted clinical guidelines. Selected Formulary and Nonformulary drugs are subject to quantity limits.
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