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Pharmacy

  • Pharmacy Policy Criteria

    For prescription drugs covered by retail or specialty
    pharmacy benefits.

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  • Enterprise Pharmacy Medical Policies

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

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  • New Century Health Program

    For oncology chemotherapeutic drug and supportive agent regimens for adults.

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  • Pharmacy Preauthorization List & UM Contacts

    See which pharmacy-related items require preauthorization and from whom.

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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.

 

PPM/10.16

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:

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.

PPM/02.21

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.

 

PPM/10.16

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

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

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

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.

 

PPM/10.16

Managed Drug Limitations

Managed drug limitations

For some drugs, we will cover only a limited quantity per prescription and/or time period for the drug. These are drugs where we have determined, in our discretion, that the number of dosages available for the drug should be limited in accordance with the proper medical use of the drug. We will make these determinations based on the drug manufacturer's suggestions, FDA guidelines, and medical literature, with input from physicians. See ConnectiCare Managed Drug Limitation List for drugs that fall into this category.

In certain cases, ConnectiCare will allow coverage of additional units above the limited number of dosages per prescription and/or time period for the drug if we determine, in our discretion, that these additional units are medically necessary. We will make this determination based on clinical evidence presented by the prescribing physician to ConnectiCare. When this occurs, members will be required to pay the applicable cost-share amount.

In addition, we reserve the right to designate that certain prescriptions be filled or refilled for no more than a 30-day supply at a time. When coverage is limited to a 30-day supply per prescription, that drug will not be available through our voluntary mail order program.

Note: One-time exceptions may be granted for specific medication upon approval. Please contact ConnectiCare's Pharmacy Services department during business hours at 800-828-3407. 

 

PPM/02.21

Benefit Exclusions

Benefit exclusions

The following is a brief summary of some of the drug products that are excluded from ConnectiCare’s plan benefits:

  • Any prescription drug not required for the treatment or prevention of illness or injury including prescriptions for cosmetic treatment or hair loss.
  • Any prescription drug obtained for the use of another individual.
  • Drugs that are lost, stolen, or damaged after they are dispensed by the pharmacy will not be replaced.
  • Products limited in use as suggested by manufacturers, the U.S. Food and Drug Administration (FDA), and ConnectiCare’s Pharmacy Services Department.
  • Weight control drugs, antibacterial soap/detergent, shampoo, toothpaste/gel, or mouthwash/rinse.
  • Medication for sexual dysfunction, unless the member is covered for such medication under a Prescription Drug Rider.
  • Drugs that may be purchased without a prescription, including prescription drugs with non-prescription OTC equivalents, are excluded.

 

PPM/10.16

Pharmacy Services Program

Pharmacy services program

Most ConnectiCare Medicare Advantage members have prescription drug coverage included in their benefit plan. Generally, members with prescription drug coverage must obtain their prescriptions from participating providers and fill them at pharmacies participating in the plan. ConnectiCare's network of pharmacies consists of more than 60,000 participating pharmacies located nationwide. ConnectiCare encourages utilization of cost-effective medications through the use of a drug formulary and the mail-order drug program. Medications appearing on the formulary are covered with their applicable cost-share for members who have prescription drug coverage, as defined by their benefit plan. Members are afforded the opportunity to fill prescriptions for maintenance medications in retail settings with the potential for lower cost-share. Experimental or investigational drugs (i.e., non-FDA-approved), are excluded from coverage.

Tier cost-share structure:

  • Tier 1 copay: preferred generic drugs
  • Tier 2 copay: generic drugs
  • Tier 3 copay: preferred brand drugs
  • Tier 4 copay: non-preferred brand drugs
  • Tier 5 coinsurance: specialty drugs

 

Medicare PPM/12.11

Medical Benefit Injectables

Medical benefit injectables

Part B medications included on this list are typically administered by a health care professional and require preauthorization before they are administered. Depending on the drug, preauthorization requests will be reviewed by us or our partner:

  • New Century Health (NCH) - Submit requests to NCH by:
    • Going to my.newcenturyhealth.com (sign in required), or
    • Calling NCH's Utilization Management Intake department at 888-999-7713 option 1, between 8 a.m. and 8 p.m. (ET) Monday through Friday.
  • Care Continuum (CCUM) – Submit requests to CCUM:

Injectable drugs (either a pharmacy benefit or a medical benefit)
Some injectables may be covered as either a pharmacy benefit (Part D) or a medical benefit (Part B). These injectables have been approved by the Food and Drug Administration (FDA) for several indications. Therefore, the way they are covered depends on the diagnosis and/or the specific formulations, setting of administration, and method of administration.

 

Medicare PPM/01.21

2023 Medicare Cost-Sharing for Insulin and Part D Vaccines

We would like to remind you that starting Jan. 1, 2023, the following changes will apply to our ConnectiCare and EmblemHealth Medicare Advantage Prescription Drug plans (MAPD) and Prescription Drug Plan (PDP) members’ cost-sharing responsibilities:

  • Members will pay no more than $35 for a one-month supply of covered insulins.
    • Members with low-income subsidy or extra help will pay less.
    • Insulins are not subject to deductible or coverage gap.
  • Members will pay $0 for most Part D vaccines.
    • Applies whether or not deductible has been met.
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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your  plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.