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The Drug Formulary is the cornerstone of drug therapy quality assurance and cost containment efforts. The Drug Formulary process has been successfully used by hospitals and managed care organizations to provide comprehensive, cost-effective pharmacy services. The Drug Formulary document was developed by the Medical Associates Health Plans Pharmacy and Therapeutics Committee (P&T Committee). This committee, composed of physicians from various medical specialties, reviewed the medications in all therapeutic categories based on safety, effectiveness, and cost and selected the most cost-effective agent(s) in each class. Formulary development and maintenance is a dynamic process. The P&T Committee will regularly review new and existing medications to ensure the Formulary remains responsive to the needs of our members and providers. The Formulary will be updated periodically by newsletter notification. As you use the Formulary, we invite your suggestions to improve the format or content. Thank you for your cooperation. |
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The Drug Formulary is a listing of medications marketed at the time of the Formulary printing and intended for use by the health plan physicians and pharmacy providers. Unless exceptions are noted, all forms (tablet, capsule, liquid, topical) and strengths of a drug product are included in the Formulary and will be covered by the plan. The Drug Formulary applies only to prescription medications dispensed to outpatients by participating pharmacies. The Formulary does not apply to inpatient medications or to medications obtained from and/or administered by a physician. |
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Over-the-counter (OTC) products are not covered, but some are listed for informational purposes. When available, non-prescription products may be less costly to the patient than a covered product. Also, if a prescription product is available in the identical strength, dosage form, and active ingredient (s) as an OTC product, the prescription product will not be covered. In these instances, physicians and pharmacists should refer members to the OTC equivalent product. If the member or physician insists on the prescription equivalent product, the member must pay the entire cost of the prescription. |
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Most listings are preceded by a "relative cost index," represented by a series of one to five dollar signs ($) or five exclamation points (!!!!!). This is a relative indication of the cost to the health plan for medications within selected therapeutic categories:
Cost ranges are applicable to the therapeutic categories listed below the cost range listing. Cost ranges reflect cost/day of therapy or cost/prescription based on prevalent dosing patterns as indicated. The relative cost index does not necessarily reflect costs that may be incurred by non-health plan members. |
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Specified drugs which have generic equivalents are covered at a generic reimbursement level, and should be prescribed and dispensed in the generic form. These drugs are indicated by the work (generic) in the Drug Formulary. Maximum Allowable Cost (MAC) limits of reimbursement have been established for these drugs and are listed in the health plan MAC list. Providers are reminded or the following:
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This policy requests that pharmacists dispense a preferred manufacturer's version of a limited number of dual-marketed brand name products. The preferred products are included in the Formulary, whereas the non-preferred products are non-formulary for plan members. Products affected by the Brand Interchange Policy are designated with the pound (#) symbol. For summary reference, refer to the Brand Interchange List. |
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The member's Certificate of Coverage states medications will be eligible for coverage only if they are FDA approved medications used for non-experimental indications. Non-experimental indications include the labeled indications(s) (FDA-approved) and the other indications accepted as effective by the balance of currently available scientific evidence and informed professional opinion. Experimental and investigational drugs, and drugs used for cosmetic purposes, are not eligible for coverage. |
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Physicians are expected to comply with the Drug Formulary when prescribing medications for plan members. If a pharmacist receives a prescription for a non-Formulary medication, the pharmacist will attempt to contact the physician to request a change to a Formulary product. If the physician is unwilling to change, or is unavailable, the pharmacist will dispense the prescription as written. The P&T Committee will monitor prescriptions written in non-conformance with the Formulary and contact physicians who prescribe non-Formulary products to request compliance. |
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The member will pay only the applicable copay for the prescription unless one of the following conditions applies:
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The physicians consulted in
Formulary development attempted to include medications for all therapeutic
needs. If a patient requires medication that is not covered, the physician
may request an exception to allow payment for the not covered medication. It
is anticipated that such exceptions will be rare, and physicians should be
able to find a Formulary medication for the vast majority of therapeutic
needs. However, if a physician wishes that a member receive a not covered
product, the physician must call the health plan or submit a letter
explaining the necessity, past therapeutic failures, and patient
identification (name, address and member number). |
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Medical Associates Health Plans |
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If a physician provider requests that a new or existing medication be added to the Drug Formulary, a letter indicating the significant advantages of the drug product over current formulary medication should be mailed to the above address. |
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