Independence has contracted with FutureScripts®, an
independent pharmacy benefit manager, 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,
Independence 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: Includes most generic medications. Drugs
are covered at the lowest formulary level of
cost-sharing.
- Tier 2 ? Preferred Brand: Includes preferred brand
medications. Drugs are covered at a higher formulary level
of cost-sharing.
- Tier 3 ? Non-Preferred Drug: 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 or call 1-800-ASK-BLUE
to request a printed copy.
Mail-order services
FutureScripts provides mail-order services as an option for Independence
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
originator 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 generally 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 medically
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 dispensed.
Exceptions
When necessary, consideration for an exception can be requested for a
non-preferred 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/Cost Share Exception Request form has been
faxed to FutureScripts at 1-888-671-5285
and contains at least the following information:
- – diagnosis for the drug requested
- – medication history
- – supporting medical information for the requested medication
The request form can be found
here.
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, Independence 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
Prior authorization is required for certain covered drugs to review whether
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 once
completed information from the prescribing
physician has been received. The prescriber will be notified if an approval has
a defined time frame, such as
12 months. Once the approval time period elapses, the physician will need to
request consideration for a new prior
authorization. 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.
Age limits
Upon approval of a drug, the FDA indicates specific safety limitations that
govern prescribing practices. Age 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
may 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.
Quantity limits
Certain drugs have a limit on how many doses a member can receive per month.
Quantity limits are based upon FDAapproved
maximum daily doses and/or length of therapy of a particular drug. If medically
necessary, a physician can
request consideration for a quantity limit exception by completing the General Pharmacy form.
Go here for
additional information on pharmacy policies and programs.
FutureScripts is an independent company that provides
pharmacy benefits management services.