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Formulary
Medical Associates Health Plans (MAHP) manages pharmacy utilization by directing our focus on three key areas:
These are the areas where we have direct control. For the fourth area, ingredient cost, we rely on our Pharmacy Benefit Management (PBM) Company, MedImpact, for contracting and rebates. MAHP utilizes what is known as a closed formulary to help manage rising pharmacy costs. Our Pharmacy and Therapeutics Committee, comprised of representatives from our participating physicians and network pharmacists, meets every other month to review requests for additions/deletions of medications, step therapies etc. to the formulary. Any additions/deletions or implementation of step therapy must receive approval by the majority of the Committee. Once approved, the formulary is updated and the changes to the formulary are sent out to all participating physicians. Click here for the most current Formulary. 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 the formulary product. If a plan member requires a medication that is not on the formulary, you may request an exception to allow coverage of the medication.
If you become aware of a member who will be leaving the service area on vacation and will require a refill prior to the return to the service area, please have the member contact our office at the above numbers to request an early refill. A prior authorization can be done so that the member can have the prescription filled prior to his/her departure. Maintenance Drug List…Medical Associates Health Plans (MAHP) has what is known as a maintenance drug list. It is a listing of medications that have been determined by the Pharmacy & Therapeutics Committee as qualifying for a 90-day supply. Many factors are reviewed before a medication is added to the list i.e. safety of medication dispensed in large quantity, cost, etc. On an annual basis, the P& T Committee reviews the medications listed and as indicated obtains the appropriate specialty group input and review. A 30-day trial is required on all “new” prescriptions for a Maintenance drug prior to obtaining a three-month supply. This means that even though a new member has been on a medication that is on our Maintenance list, the member will need to be on the medication for 30 days under MAHP prior to receiving a three-month supply. Click here for the most recent Maintenance Drug List. Mail Order…The medications on the maintenance drug list also qualify for mail order, which means that the three-month supply is available for two co-pays. Mail order service results in a savings not only for our members but also for MAHP. Click here to access WellDyneRX mail order. Mail Order:
Over-The-Counter (OTC) Medications… MAHP’s policy has been that we do not cover OTC’s that do not require a physician’s authorization by state or federal law and any prescription medication that is available as an OTC medication or for which there is an OTC alternative. The OTC medication remains the member’s responsibility. Maximum Allowable Cost (MAC)…Medications that have generic equivalents are covered at a generic reimbursement level and should be prescribed and dispensed in the generic form. Maximum Allowable Cost (MAC) limits of reimbursement have been established for these drugs. If a physician indicates “Dispense as Written” (DAW), or if a member insists on the brand name medication for a medication included in the MAC list, the patient must pay the applicable co-pay and would also be responsible for the cost difference between the brand name drug and the MAC amount (ancillary charge). If a member requests a non-formulary medication from you, please indicate this by writing “Requested by Member” on the prescription. That way, the member will be responsible for the entire cost of the medication and the pharmacist will not attempt to contact you for a formulary substitution. Formulary Addition Requests… If you have a request to add a medication to our Formulary, please fill out the Formulary Request Form. This form provides the necessary information required for review by the Pharmacy and Therapeutics Committee. All requests are discussed and reviewed and either approved or denied by the P&T Committee. Requests from drug representatives to add medications to our formulary are not taken to the P&T Committee. To obtain this form, please contact Health Care Services at 584-3275 or 1-800-325-7442 and we will send it out to you.
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