Pharmacy

For provider administered drugs covered by medical benefits and oncology services which are not in scope for the New Century Health Program.

1. Commercial
2. Medicare

Pharmacy & Therapeutics Committee

Pharmacy & Therapeutics Committee

The ConnectiCare Drug List is overseen by the Pharmacy and Therapeutics (P&T) Committee. This committee is responsible for overseeing drug utilization and quality drug therapy including the ConnectiCare drug formulary.

The P&T Committee is comprised of primary care and specialty physicians and community pharmacists who participate with ConnectiCare's Chief Medical Officer, the VP of Pharmacy Solutions, Director of Pharmacy Operations, and clinical pharmacists. The role of the P&T Committee is to provide advice and/or consent regarding the development, review, and revision of ConnectiCare's pharmaceutical management procedures. In addition, the Committee performs regular review of new drugs and drug classes to determine placement on the formulary.

The P&T Committee meets quarterly, or as needed, and functions as a subcommittee of ConnectiCare's Quality Management Committee.

Product Selection Criteria

The P&T Committee examines objective characteristics of an individual drug during its evaluation for tier placement on the ConnectiCare drug list, as well as during its periodic examination of entire therapeutic drug classes.

When a new drug is considered for addition to the list, the committee consults medical literature and expert medical opinion relative to other similar drugs currently on the list, particularly with regard to the following:

• indication
• safety
• efficacy
• effectiveness
• utilization
• cost
• comparison studies
• approved indications
• adverse effects
• pharmacokinetics
• patient compliance considerations
• medical outcome and pharmacoeconomic studies

Entire therapeutic classes are reviewed at least annually in an effort to continually promote the most clinically useful and cost-effective agents in a particular therapeutic class. All drugs are covered except for a small number specifically excluded by benefit design. Some drugs require preauthorization or step therapy designated by the P&T Committee.

Pharmacy Preauthorization Requirements

Preauthorization requirements

Some drugs, due to their narrow indication, potential for misuse, or high cost, require preauthorization to ensure appropriate access and use. Before these drugs will be covered, the physician must forward the medical rationale for the drug selection for coverage review. The drug will be approved or denied for coverage based on criteria established and approved by the P&T Committee. Some drugs within the preauthorization program require other medications be used prior to approval (Step Therapy).

Drugs on the preauthorization list are rejected at the pharmacy unless they have been preauthorized by ConnectiCare.

Preauthorization requests can be submitted the following ways:

• Electronic prior authorization (ePA) using your certified e-prescribing software
• Visiting Express Scripts
  
• By fax using the appropriate pharmacy preauthorization form

The following information should be supplied when requesting preauthorization:

1. Member's name, address, and ConnectiCare ID number
2. Provider name, address, and phone number
3. Drug, strength, quantity, dosage form, and directions
4. Indication for use
5. Anticipated length of therapy
6. Dose and frequency of treatment for physician-administered drugs
7. Information to support request (drug history and medical history)
8. Reason for request (e.g., allergy, failure with other medication)

Please refer to the ConnectiCare Drug Preauthorization List to see drugs that require preauthorization.

What happens next?

• Utilization Management Pharmacists will review the request for authorization and decide.
• When a request for authorization is denied, the physician will be notified in writing, including: the reason for the determination and clinical rationale; instructions on how to initiate an appeal of the decision; and notice of the availability of the medical necessity criteria referenced in the decision.

Specialty Prescription Drugs

Specialty prescription drugs

Certain specialty prescription drugs require preauthorization and must be filled through specialty pharmacies. These drugs consist of self-injectable, infusion, oral drugs requiring special handling, and drugs not typically stocked by retail pharmacies. See the ConnectiCare Specialty Prescription Drug Preauthorization List for drugs that fall into this category.

Physicians will be notified of the number to contact the specialty pharmacy if preauthorization is granted. When preauthorized, specialty drugs will be dispensed for a maximum of a 30-day supply per fill. Contact information for the specialty pharmacy can also be obtained by calling Provider Services at 800-828-3407. The drugs will be shipped to the physician's office, the member’s home, or other designated location. Specialized counseling and education is available to patients from the specialty pharmacies regarding proper administration, storage, dosage, drug interactions, and side effects of these specialty drugs.

Generic Substitution Program

Generic substitution program

Generic substitution is the process by which a generic equivalent is dispensed rather than the corresponding brand-name product. ConnectiCare benefit designs promote the use of generic drugs when available and, in many cases, we require additional member cost-share if the generic is not dispensed, even if the physician writes “no substitution.” The FDA has given the generic an “A” rating compared to the branded counterpart and has determined it to be therapeutically equivalent. The ratings of generic drugs are available at the Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book). ConnectiCare follows this criteria when determining if and when a generic drug is available. Please promote the use of generics whenever possible if appropriate. Below is a description of how ConnectiCare chooses which drugs to recommend in the generic form.

A couple of scenarios are available.

MAC A is a mandatory generic option.

• If the prescription does NOT indicate Dispense as Written and a generic equivalent is available, the generic drug is automatically dispensed.
• If the prescription does NOT indicate Dispense as Written and a generic is available and the member requests the brand name drug, the brand-name drug is dispensed with the member paying the copayment/coinsurance of the first tier plus the difference between the cost of the brand and the generic drug.
• If the prescription indicates Dispense as Written and a generic is available, the brand-name drug is dispensed with the member paying the copayment/coinsurance of the first tier plus the difference between the cost of the brand and the generic drug.

MAC B is the generic preferred physician's choice option.

• If the prescription does NOT indicate Dispense as Written and a generic equivalent is available, the generic drug is automatically dispensed.
• If the prescription does NOT indicate Dispense as Written and a generic is available and the member requests the brand name drug, the brand-name drug is dispensed with the member paying the copayment/coinsurance of the first tier plus the difference between the cost of the brand and the generic drug.
• If the prescription indicates Dispense as Written and a generic is available, the brand-name drug is dispensed with the member ONLY paying the copayment/coinsurance of the tier with which the brand-name drug is associated.

MAC C is the voluntary option.

• If the prescription does NOT indicate Dispense as Written and a generic equivalent is available, the generic drug is automatically dispensed.
• If the prescription does NOT indicate Dispense as Written and a generic is available and the member requests the brand-name drug, the brand name drug is dispensed with the member ONLY paying the copayment/coinsurance of the tier with which the brand name drug is associated.
• If the prescription indicates Dispense as Written and a generic is available, the brand-name drug is dispensed with the member ONLY paying the copayment/coinsurance of the tier with which the brand name drug is associated.

The member should review their summary of benefits or contact their benefits administrator to determine which MAC schedule applies.