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Prescription Drug Benefit Health Choices manages pharmacy utilization by directing our focus on three key areas:
These are the areas where we have direct control. For the fourth area, ingredient cost, we rely on our Pharmacy Benefit Management (PBM) Company, Express Scripts, for contracting and rebates. Health Choices utilizes what is known as a closed formulary to help manage rising pharmacy costs. Our Pharmacy and Therapeutics Committee, comprised of representatives from our participating physicians and network pharmacists, meets every other month to review requests for additions/deletions of medications, step therapies etc. to the formulary. Any additions/deletions or implementation of step therapy must receive approval by the majority of the Committee. Once approved, the formulary is updated and the changes to the formulary are sent out to all participating physicians. Click here for the most current Formulary. Once you are in the formulary, you will notice that the drugs are in two colors:
Once you have located the medication you are wishing to view, please click on medication and you will go deeper into the formulary where any prior authorization requirements are listed, as well as formulary alternatives for non-formulary medications, and any step therapy requirements. The drug listing is preceded by a "relative cost index." The range goes from $ to $$$$ which reflects least expensive product up to the more expensive product to the range of !!!!! which means the product is substantially more expensive that previous medications listed. Cost ranges reflect cost/day of therapy or cost/prescription based on prevalent dosing patterns as indicated. Physicians are expected to comply with the Drug Formulary when prescribing medications for plan participants. If a pharmacist receives a prescription for a non-formulary medication, the pharmacist will attempt to contact the physician to request a change to the formulary product. If a plan participant requires a medication that is not on the formulary, you may request an exception to allow coverage of the medication.
If you become aware of a participant who will be leaving the service area on vacation and will require a refill prior to the return to the service area, please have them contact our office at the above numbers to request an early refill. A prior authorization can be done so that the member can have the prescription filled prior to his/her departure. Maintenance Drug List Health Choices has what is known as a maintenance drug list. It is a listing of medications that have been determined by the Pharmacy & Therapeutics Committee as qualifying for a 90-day supply. Many factors are reviewed before a medication is added to the list i.e. safety of medication dispensed in large quantity, cost, etc. On an annual basis, the P& T Committee reviews the medications listed and as indicated obtains the appropriate specialty group input and review. A 30-day trial is required on all "new" prescriptions for a Maintenance drug prior to obtaining a three-month supply. This means that even though a new participant has been on a medication that is on our Maintenance list, the Participant will need to be on the medication for 30 days under Health Choices prior to receiving a three-month supply. |
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