Carefirst formulary sklice

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Page created by Dawn Barker. Page content transcription If your browser does not render page correctly, please read the page content below. The PDL does not define benefit coverage.

Guidance is based on similarities and differences compared with other medications that treat the same disease or condition.

The tier placement of a medication on the PDL may change. While medications change tiers infrequently, such changes generally occur up to 3 times per calendar year. Additionally, when a brand-name medication becomes available as a generic, the tier status and coverage of the brand-name medication and its corresponding generic will be evaluated.

When a medication changes tiers, your patient may be required to pay more or less for that medication. These changes may occur without prior notice to you or your patient. However, you may visit our website at UHCprovider. Your patient can also find the most up-to-date tier status and cost3,8 information for a particular medication by visiting our member website at myuhc. Tier designations Prescription medications are categorized within 3 tiers on the PDL. You may refer to the PDL as a guide to select the most appropriate medication with the lowest member cost for your patients.

You and your patient make decisions about health care and medication treatments. Some members have a 4-tier prescription plan, and these medications are noted as T4 throughout the document.

Not all medications are represented in this PDL. Only the most commonly prescribed medications are included. Over-the-counter and therapeutically equivalent medications For some conditions, you and your patient may decide that an over-the-counter OTC medication is the most appropriate treatment.

According to UnitedHealthcare benefit design, OTC medications are defined as medications that do not require a prescription by federal or state law to be dispensed. Our benefit designs allow us to exclude a medication if determined to be Therapeutically Equivalent to another covered product or OTC option. When a generic medication does not offer significant financial savings, it may be placed in the same tier or a higher tier than the brand medication.

Generic medications are noted in italic font. Members may be required to pay more for a prescription when a higher-tier brand-name product is dispensed. When generic substitution conflicts with state regulations or restrictions, the pharmacist must obtain approval from the prescribing physician or other health care professional to substitute the generic equivalent.

Specialty medications Some members may have coverage for self-administered injectable and oral specialty medications through their pharmacy benefit plan.

You will find these medications included in the body of this document within the appropriate therapeutic categories. UnitedHealthcare has a specialty pharmacy program that requires most specialty medications to be obtained through a designated specialty pharmacy. These medications are noted by SP throughout the document. The specialty pharmacy program includes designated specialty pharmacies, 3.

Their pharmacists are trained to help educate patients for these specialty medications, which may help improve treatment adherence. Participating members should be instructed to call the toll-free member number on their ID card where a representative will answer questions about our program and then transfer them to a specialty pharmacy based on their particular specialty medication prescription. Such medications are noted with a PA. The pharmacy benefit may exclude coverage of medications for certain uses.

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Depending on your plan, prescription drugs fall into one of five drug tiers which determines the price you pay. Some plans may have 3, 4 or 5 tiers, so be sure to check your benefits information to see which tiers are included. Members can view specific cost-share copay or coinsurance information by logging in to My Account to access the Drug Pricing Tool or by reviewing their annual summary of benefits. Here's Why. Skip Navigation. Login Register. Have questions about health insurance?

Explore our Insurance Basics pages. Need Insurance? Log In or Register. Oral chemotherapy drugs and diabetic supplies e. Generic drugs generally cost less than brand-name drugs. Non-preferred brand drugs often have a generic or preferred brand drug option where your cost-share will be lower. These drugs may have a lower cost-share than non-preferred specialty drugs. Non-preferred specialty drugs often have a specialty drug option where your cost-share will be lower.

This program addresses the unique clinical needs of those taking high-cost specialty drugs for certain diseases like multiple sclerosis and hemophilia. This program provides enhanced one-on-one support with a registered nurse, hour pharmacist assistance, condition-specific education and counseling and a dedicated clinical team to work with your doctor to help manage specialty drugs. When you are taking multiple drugs to treat a medical condition, it can be overwhelming.

The Comprehensive Medication Review program can connect you with a CVS Caremark pharmacist who will review your medications and talk to your doctor about dosages, duration and any other pertinent issues. The pharmacist will work with your doctor to determine which medications best fit your situation. Medications do not work if they are not taken as prescribed. Pharmacists are alerted to gaps in care and non-adherence and provide in-person one-on-one counseling when the prescription is filled at a CVS pharmacy.

If the prescription is filled through mail order or at other network pharmacies, one-on-one telephonic counseling is offered to help you stay on track. The pharmacist will provide personalized tips and support to help you stay adherent to your medications and identify potential opportunities for you to save money on your prescriptions.

To ensure you are receiving the most appropriate medication for your condition s , certain medications have prescription guidelines. To see whether your drug requires prior authorization, step therapy or quantity limits, use our Drug Search.

If you fill a non-preferred brand drug when a generic alternative is available, you will pay the non-preferred brand copay or coinsurance plus the cost difference between the generic and non-preferred brand drug, even if your doctor states Dispense as Written DAW on the prescription.

There is an exception process if you need the brand-name drug to be covered for medical necessity reasons. Your doctor may submit a brand exception request. To view this form, check our Drug Forms. Prior authorization is required before you fill prescriptions for certain drugs. Your doctor must obtain prior authorization before they can be filled. Without prior authorization approval, your drugs may not be covered. Step therapy ensures you receive a lower-cost drug option as the first step in treating certain health conditions.

When similar drugs are available, step therapy guides your doctor to prescribe the lower-cost option first. You may then move up the cost levels until you find the drug that works best for you. Higher step drugs may require prior authorization by your doctor before they can be covered.

Quantity limits are placed on selected drugs for safety, quality or utilization reasons. Limits may be placed on the amount of the drug covered per prescription or for a defined period of time.

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