AmeriHealth has contracted with FutureScripts^® to manage the administration and claims processing of our prescription drug programs. FutureScripts provides mail-order services and works with community pharmacies to provide medications to our members. Medication claims are generally processed directly with the pharmacy provider when the member obtains the prescription.

In order to oversee our pharmacy policies and procedures and to promote the selection of clinically safe, clinically effective, and economically advantageous medications for our members, AmeriHealth formed the Pharmacy and Therapeutics Committee. This Committee is a group of local physicians and pharmacists who meet quarterly to review, evaluate, and update the medications included in our formularies to ensure their continued effectiveness, safety, and value.

Select Drug Program^®

The Select Drug Program is a formulary-based drug benefits program that is maintained by the Pharmacy and Therapeutics Committee and includes all generic drugs and a defined list of brand-name drugs that have been reviewed for medical effectiveness, safety, and value and approved by the U.S. Food and Drug Administration (FDA). This program is set up with a three-tiered cost-sharing structure:

• Tier 1 – Generic formulary: Includes most generic medications. Drugs are covered at the lowest formulary level of cost-sharing.
• Tier 2 – Brand formulary: Includes preferred brand medications. Drugs are covered at a higher formulary level of cost-sharing.
• Tier 3 – Brand non-formulary: Includes non-preferred medications. Drugs are covered at the highest non-formulary level of cost-sharing.

Coverage for drugs is based on the member?s prescription drug benefits. You can download the latest Select Drug Program formulary for AmeriHealth New Jersey or at the latest Select Drug Program formulary for AmeriHealth Pennsylvania. For a printed copy, call Provider Services at 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey or at 1-800-275-2583 for AmeriHealth Pennsylvania.

Mail-order services

FutureScripts provides mail-order services as an option for AmeriHealth members to receive their medications. Most of the time, medication requests are processed upon receipt of a prescription from a physician; however, there may be times when the physician will need to contact FutureScripts for medication coverage, such as when formulary management limitations exist. See the ?Prescribing safety? section below for more details.

Generic medications

According to the FDA, generic drugs are equivalent to their brand-name alternatives in active ingredients, dosage, safety, strength, and performance and are held to the same strict standards as their brand-name counterparts. The only noticeable difference between a generic drug and its brand-name counterpart may be the shape and/or color of the drug. Generic drugs are just as effective as the corresponding brand-name drugs; however, they may cost up to 70 percent less, helping to reduce health care costs for members. The generic option is always the lowest cost for the member.

Please note that FutureScripts does not determine when a generic medication will be provided at the pharmacy. In accordance with state laws, generic medications may be provided by the pharmacist at the point of sale, if available, unless the physician indicates "dispense as written? or ?brand necessary? on the prescription. However, if brand medications are prescribed in place of a generic medication, prior authorization may be needed before the drug is covered.

Exceptions

When necessary, consideration for an exception can be requested for a non-formulary medication to be covered at the formulary level of cost-sharing. Physicians may request coverage on behalf of a member when the following conditions are met:

• All formulary alternatives have been exhausted or there are contraindications to using them.
• A completed Formulary Exception Request form has been faxed to 1-888-671-5285 and contains the following information:
• diagnosis for the drug requested
• medication history
• supporting medical information for the requested medication

If the non-formulary exception request is approved, the physician will receive written notification and the drug will be processed at the appropriate formulary level of cost-sharing. If the request is denied, the physician and member will receive a denial letter.

Prescribing safety

As part of formulary management, AmeriHealth implements safe prescribing procedures that are designed to optimize the member?s prescription drug benefits by promoting appropriate utilization. These procedures are based on FDA guidelines, and the approval criteria were developed and endorsed by our Pharmacy and Therapeutics Committee. FutureScripts continuously monitors the effectiveness and safety of drugs and drug prescribing patterns. Several procedures support safe prescribing patterns for our prescription drug programs, such as prior authorization and age, gender, and quantity limits.

Prior authorization is required for certain covered drugs to ensure that the drug is medically necessary, appropriate, and prescribed according to FDA guidelines. The approval criteria for these medications may include that the physician order a trial of a different drug, such as a generic or a therapeutic alternative. Clinical pharmacists evaluate the information submitted by the member?s prescribing physician, including available prescription drug therapy history. The clinical pharmacists determine whether there are any drug interactions or contraindications, that the dosing and length of therapy are appropriate, and that other drug therapies, if necessary, were utilized where appropriate.

The prior authorization process may take up to two business days (24 hours for urgent requests) once completed information from the prescribing physician has been received. Some drugs may have approval duration limits of 6 or 12 months. This means that after 6 or 12 months, the physician will need to request consideration for a new prior authorization. The prescriber is notified upon approval whether a limited approval duration exists. Physicians should fax the appropriate prior authorization form and all supporting medical information to FutureScripts at 1-888-671-5285. The prior authorization forms are available on the FutureScripts website.

Upon approval of a drug, the FDA indicates specific safety limitations that govern prescribing practices. Age and gender limits are designed to prevent potential harm to members and to promote appropriate use. Pharmacists have access to up-to-date information regarding FDA guidelines. If a member?s prescription falls outside of the FDA guidelines, it will not be covered until prior authorization is obtained. The prescribing physician may request consideration for prior authorization of these medications when medically necessary by completing the General Pharmacy form. The member should contact the prescribing physician to request that he or she initiate the prior authorization process.

Certain drugs have a limit on how many doses a member can receive per month. Quantity limits are based upon FDA-approved maximum daily doses and/or length of therapy of a particular drug. Quantity limits ensure that a drug is not taken in the wrong way and that the member does not take more than the FDA-approved maximum daily dose or length of therapy. If medically necessary, a physician can request consideration for a quantity limit exception by completing the General Pharmacy form.