system. Medco uses criteria developed by their Pharmacy and Therapeutics Committee and they are reviewed and adopted by the Plan. The Plan or Medco may contact your provider if additional information is required to determine whether Prior Authorization should be granted. Medco or Plan communicates the results of the decision to both you and your provider.
If Prior Authorization is denied, written notification is sent to both you and your providers. You have the right to appeal through the appeals process. The written notification of denial you receive provides instructions for filing an appeal.
To ask if a drug requires Prior Authorization, please contact Medco at the Customer Service telephone number on the back of your ID card.
You, your provider, or pharmacist, may check with Medco to verify covered prescription drugs, any quantity and/or age limits, prior authorization or other requirements of the Plan.
Formulary or preferred drug list
A formulary is a list of commonly prescribed medications from which your physician may choose to prescribe. The formulary is designed to inform you and your physician about quality medications that, when prescribed in place of other non-formulary medications, can help contain the increasing cost of prescription drug coverage while maintaining the high quality of care.
You may request a copy of the preferred drug list or formulary by calling Medco at the Customer Service telephone number on the back of your ID card or view the list online at www.medco.com. The preferred drug list is subject to periodic review and amendment and the inclusion of a drug or related item on the preferred drug list is not a guarantee of coverage.
Therapeutic Interchange is a formulary management program approved by the Plan and managed by Medco. This is a voluntary program designed to inform members and physicians about possible alternatives to certain prescribed drugs. Medco may contact you or your prescribing physician to make you aware of preferred alternatives. Therapeutic interchange may also be initiated at the time the prescription is dispensed. For questions or issues involving therapeutic drug substitutes, contact Medco by calling the Customer Service telephone number on the back of your ID card. The therapeutic interchange drug list is subject to periodic review and amendment. No change in the medication prescribed for you will be made without your physicians’ approval.
Step Therapy The Plan participates in programs to encourage the prescribing of generics and lower cost alternative preferred brand drugs. These programs may produce savings to you. Step therapy protocol means that a member may need to use one type of medication before another. If physician approved, the more cost-effective medication will be dispensed. If the physician does not approve and prefers a non-preferred drug, prior authorization is needed.
Specialty Pharmacy Network “Specialty Drugs” are prescription legend drugs which:
Are used to treat complex conditions such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis, and rheumatoid arthritis.
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