Prescription Drug Cost Management Programs

As a medical plan participant, you may be required to follow program procedures in order for your medication to be covered. This section provides an overview of the programs. Detailed information is located on Medical Mutual’s website at medmutual.com.

1. Specialty Drug Solution Program—Specialty drugs are medications that require special handling, administration or monitoring. They are often used to treat rare, complex and chronic conditions. These drugs are usually injected but may be taken by mouth.

When using the Specialty Drug Solution Program, covered participants receive a variety of specialized services including:

• Safe, prompt delivery of medications
• Access to personalized care from dedicated nursing and pharmacy staff
• Supplies that accompany certain types of medications
• 24/7 support services
• Refill reminders
• Drug safety monitoring
• Help with enrolling in patient assistance programs

Contact either Accredo or Gentry, and they will contact your prescriber for your prescription. Your prescriber can also call in or fax the prescription.

• Accredo Specialty Pharmacy
  • Phone: 800.803.2523
  • Fax: 888.302.1028
• Gentry Health Services
• Phone: 844.443.6879
• Fax: 844.329.2447

2. Prior Authorization for Prescriptions—To be covered, certain prescription drugs require the covered member to obtain an approval through the coverage review process prior to filling your prescription. To initiate the coverage review process, the member, the member’s doctor or pharmacist may call Express Scripts at 800.753.2851.

   Express Scripts’ “Price a Medication” tool on their website will tell you if a medication is subject to this cost management program. Once you have logged into your account, select “Prescriptions,” and then “Price a Medication” from the menu bar. If coverage is approved, members pay the normal copayment for the medication. If coverage is not approved, the member will be responsible for the full cost of the medication. Note: Members have the right to appeal the decision. Information about the appeal process will be included in the notification letter they receive.

3. Quantity Limit—Some prescription drugs will be covered only up to a certain quantity limit per fill. This list generally includes medications that are not taken every day. Getting quantities beyond the predetermined limit requires prior authorization from Express Scripts. Express Scripts’ “Price a Medication” tool on their website will tell you if a medication is subject to this cost management program. Select “Prescriptions” and then “Price a Medication” from the menu bar.

4. Preferred Drug Step Therapy—CSU medical plan rules require the use of a generic or lower-cost brand-name alternative before use of higher cost non-preferred drugs can be covered by the Plan, unless special circumstances exist. Express Scripts’ “Price a Medication” tool on their website will tell you if a medication is subject to this cost management program. Once you have logged into your account, select “Prescriptions” and then “Price a Medication” from the menu bar. Members using one or more of the medications on the list will need to switch to a generic or a preferred brand-name drug. Members who do not switch will pay the full price for their medication.

   Express Scripts will use an automated process to determine if a member qualifies for coverage based on information that Medical Mutual has on file, which includes medical history, drug history, age and gender. If a member’s physician believes special circumstances exist, he/she may request a coverage review by calling Express Scripts at 800.753.2851.

5. Compound Medications are Excluded from Coverage—Compound medications are made when a licensed pharmacist combines, mixes or alters a medication’s ingredients to meet a doctor’s request. Compounded medications are not reviewed as final products by the U.S. Food and Drug Administration (FDA), so there is no way for the FDA to confirm their quality, safety and effectiveness. In addition, compound medications often come at an unusually high cost even though alternatives exist at a lower cost. As a result, the Plan will not provide coverage for compounded medications. Covered members wishing to use these medications will be responsible for paying the full cost.
6. RationalMed Drug Safety Program—This Medical Mutual/Express Scripts safety program that uses medical and drug claim data to help identify potential safety issues. The program checks for adverse drug risks, coordination of care and omission of essential care, alerting prescribing physicialns as needed.