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Select Drug Formulary Update
February 20, 2009
Beginning April 1, 2009, AmeriHealth will make some updates to the Select Drug Program®. We would like to provide you with a list of our most recent changes to the drug formulary and some updates to our support of the safe prescribing of drugs.
Updates to the formulary and safe prescribing procedures
Our formulary is the key to the Select Drug Program. The formulary includes all generic drugs and some brand drugs that have been selected for their medical effectiveness, safety, and value.
The FutureScripts® Pharmacy and Therapeutics Committee, whose members include practicing physicians and pharmacists from the area, regularly reviews the formulary and safe prescribing procedures to ensure their continued effectiveness. As a result of the committee’s recent reviews, we’re implementing the following changes:
- additions of generic drugs to the formulary;
- additions and deletions of brand drugs to or from the formulary;
- additions to our list of drugs that require the doctor to obtain prior authorization.
Click here to view a list of changes
Click here to view the complete formulary guide – effective April 1, 2009
Note: Brand drugs removed from the formulary will now be covered at the highest non-formulary cost-sharing level.
Safe prescribing procedures update for narcotic drugs
Prescription medications are necessary to effectively treat certain medical conditions. However, prescription medications have the potential to be unsafe when not used properly. We take several actions, referred to as safe prescribing procedures, to make sure that our members are using prescription drugs safely. This includes making sure the correct drugs are being prescribed and being taken in the appropriate amounts. Two of these safe prescribing measures are prior authorization and quantity limits. Prior authorization is required before certain drugs are available for coverage. Quantity limits are designed to allow a sufficient supply of medication based on FDA-approved maximum daily doses and length of therapy of a particular drug.
We are making the following changes to safe prescribing procedures for narcotic drugs effective May 1, 2009:
- Expiration of prior authorizations. We are implementing a time limit of six to twelve months on prior authorization approvals for narcotic drugs. For example, if a narcotic drug receives a six-month prior authorization on May 1, 2009, that authorization will expire on October 30, 2009. Newly approved prior authorizations will include an expiration date at the time the approval is made. If a doctor wants a member to continue the drug therapy after the expiration date, a new request will be required.
Existing prior authorizations will expire on May 1, 2009. Therefore, if a member currently has an approved prior authorization for a narcotic drug, it will expire May 1, 2009. Doctors will have to submit a new prior authorization request if he or she recommends that a member continue with the current drug therapy.
- New quantity limits. We are adding quantity limits to certain narcotics. If a members attempts to fill a prescription that exceeds the set quantity limit, the pharmacist will fill the prescription only for the allowed supply. If the doctor determines that the member’s therapy requires a larger dose of medication than the set quantity limit for the drug, he or she may request a quantity limit exception. Doctors must receive an approval for the exception for members to continue to receive coverage for therapy at a larger dose.
- Therapeutic drug class quantity limit. We are also applying a 30-day total quantity limit to each class of narcotic drugs. If a member uses more than one narcotic within the same class, or if the same drug is being taken in more than one strength, the member may be unsafely duplicating medications. Effective May 1, 2009, members will be able to obtain only a 30-day total supply of any combination of drugs in the same class each month. If a doctor recommends drug therapy that exceeds the class quantity limits, he or she must submit a request for a class quantity exception.
- Expiration of Quantity Limit Exceptions. If a quantity limit exception is approved, it will be limited to six to twelve months. For example, if a narcotic drug receives a quantity limit exception approval for six months on May 1, 2009, that approval will expire on October 30, 2009. Newly approved quantity limit exceptions will include an expiration date at the time the approval is made. If a doctor wants a member to continue the drug therapy after the expiration date, a new request will be required.
Existing quantity limit exceptions will expire on May 1, 2009. Therefore, if a member currently has an approved quantity limit exception for a narcotic drug, it will expire May 1, 2009. If the doctor feels that the therapy still requires a larger dose of medication than the set quantity limit, he or she will need to submit a new quantity limit exception request. The doctor must receive an approval for the exception for the member to continue to receive coverage for therapy at a larger dose.
Communicating to customers
All employer groups and members with Select Drug Program coverage will be notified of these changes in the spring issue of Update magazine. Comprehensive Major Medical members who do not receive Update will receive a letter notifying them of these changes. In addition, members who are directly affected by the changes detailed above will receive a letter with additional information and instructions.
We will urge members who are affected by the removal of a drug to contact their doctor to discuss formulary alternatives, including the use of generic drugs. If a doctor decides that an alternative medication is appropriate, the member will need to ask for a new prescription for that medication.
If you have questions, please contact your AmeriHealth broker representative.
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