The drug formulary is the cornerstone of drug therapy quality assurance and cost-containment efforts. The drug formulary process has been successfully used by hospitals and managed care organizations to provide comprehensive, cost-effective pharmacy services.
The Medica Formulary document is developed by the Medica Pharmacy and Therapeutics Committee (P&T Committee). This committee, composed of physicians from various medical specialties, reviews the medications in all therapeutic categories based on safety, effectiveness, and value.
Formulary development and maintenance is a dynamic process. The P&T Committee will regularly review new and existing medications to ensure that the Formulary remains responsive to the needs of our members and providers. Updates to the Formulary will be periodically provided via newsletter. The Formulary is also available on our website www.medica.com. This site is updated regularly to reflect P&T Committee recommendations and changes to the Formulary.
As you use the Formulary, we invite your suggestions to improve the format or content. Thank you for your cooperation.
Medica Formulary Medications
Non-Prescription Medication (OTC) Policy
Generic Drug Policy
Unapproved Use Of Formulary Medications
Medications Requiring Prior Authorization (PA)
Medications Requiring Step Therapy (ST)
Quantity Level Limits (QL)
Prescriptions For Non-Formulary Medications
Copay Determination
Formulary Exception Process
Formulary Requests
Medica Formulary MedicationsThe Formulary is a listing of medications intended for use by the health plan physicians and pharmacy providers. The Formulary applies only to prescription medications dispensed to outpatients. The Formulary does not apply to inpatient medications or to medications obtained from and/or administered by a physician.
return to topNon-Prescription Medication (OTC) Policy*In most cases, over-the-counter (OTC) products are not covered. Non-prescription products may be less expensive to the member than a covered product. If a prescription product is available in the identical strength, dosage form, and active ingredient(s) as an OTC product, the prescription product will not be covered. In these instances, physicians and pharmacists should refer members to the OTC equivalent product. If the member or physician insists on the prescription equivalent product, the member must pay the entire cost of the prescription.
OTC medications that are covered include Prilosec OTC, loratadine (Claritin or Claritin D), Insulin and diabetic testing supplies. OTC nicotine replacement therapies are also covered for some plans.
* This policy does not apply to members with Medicaid coverage whose pharmacy benefit includes coverage of certain OTC products.
return to topGeneric Drug PolicySpecified drugs, which have generic equivalents, are covered at a generic reimbursement level, and should be prescribed and dispensed in the generic form. These drugs are written in lower case letters in the formulary book. Drugs listed in all capital letters are available as Brand name only, however, if the generic becomes available, the Brand name will not be covered. Maximum Allowable Cost (MAC) limits of reimbursement have been established for these drugs and are listed in the health plan MAC list. Providers are reminded of the following:
- When generic substitution conflicts with state regulations or restrictions, the pharmacist must gain approval from the prescriber to use the generic equivalent.
- If a physician indicates "Dispense as Written" (DAW) or if a member insists on the brand-name product for a prescription of a medication included in the MAC list, the member will pay a higher copayment for the brand-name drug.
return to topUnapproved Use Of Formulary MedicationsThe member's Certificate of Coverage states that medications will be eligible for coverage only if they are FDA-approved medications used for non-experimental indications. Non-experimental indications include the labeled indication(s) (FDA-approved) and other indications accepted as effective by the balance of currently available scientific evidence and informed professional opinion. Experimental and investigational drugs, and drugs used for cosmetic purposes, are not eligible for coverage.
return to topMedications Requiring Prior Authorization (PA)To promote appropriate utilization, selected medications may require prior authorization. Certain prescription drugs and supplies on the Formulary require prior authorization at the point of service. The provider who has prescribed the prescription drug or supply may initiate the prior authorization process by calling:
1-800-788-2949 (Fax: 858-790-7100).
The determination is based on criteria established by Medica's P&T Committee.
return to top Medications Requiring Step Therapy (ST)Selected medications require Step Therapy. These medications will be covered only for members who have already tried and failed therapeutic alternatives as determined by Medica's P&T committee.
For more information,
click here.
return to topQuantity Level Limits (QL)Some prescription medications may be subject to quantity level limits based on the pharmaceutical manufacturer's packaging, FDA-approved labeling, or adopted clinical guidelines. These products are designated in the Formulary by "QL."
For specific quantity limits on formulary medications,
click here.
return to topPrescriptions For Non-Formulary MedicationsPhysicians are expected to comply with the Formulary when prescribing medications for plan members. If a pharmacist receives a prescription for a non-formulary medication, the pharmacist will attempt to contact the attending provider to request a change to a formulary product. If the physician is unwilling to change the prescription, or is unavailable, the pharmacist will dispense the prescription as written.
return to topCopay DeterminationThe member will pay only the applicable copay for the prescription unless one of the following conditions applies:
- If a prescription is written for a non-formulary medication, the member will be responsible for the entire cost of the prescription or the higher copay, whichever is applicable based on benefit design.
- If a physician indicates "Dispense as Written" (DAW) or if a member insists on the brand-name product for a prescription of a medication included in the MAC list, the member must pay a higher copay amount.
- If a prescription is written for a medication available as an OTC product in the identical dosage, form, strength, and active ingredient, the prescription product will not be covered. The pharmacist should refer the member to the OTC product. If the member or physician insists on the prescription equivalent product, the member will be responsible for the entire cost of the prescription.*
- If a physician prescribes a drug that is not covered and a satisfactory alternative product is unavailable, the member must pay the entire prescription cost.
* This policy does not apply to members with Medicaid coverage whose pharmacy benefit includes coverage of certain OTC products.
return to topFormulary Exception ProcessThe physicians consulted in the Formulary development attempted to include medications for all therapeutic needs. Infrequently, a member whose benefit does not cover non-formulary medications, may require a non-formulary medication. If a member requires a medication that is not covered, the attending provider may request an exception to allow coverage of the not-covered medication. Such exceptions will be rare, and attending providers should be able to find a formulary medication for the vast majority of therapeutic needs.
To request an exception please call:
1-800-788-2949 (Fax: 858-578-9732).
The determination is based on criteria established by the P&T Committee. The prescriber will be notified of an approval or denial within 48 hours.
return to topFormulary RequestsIf a physician provider requests that a new or existing medication be added to the Medica Formulary, a letter indicating the significant advantages of the drug product over current formulary medications should be mailed to:
MEDICA
Attention: Pharmacy Services
P.O. Box 9310
Mail Route: 80703
Minneapolis, MN 55440-9310
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