Prescription Drug Guidelines - IBX

Prescription drugguidelinesWhat you need to know H ow to find out what prescription drugsare covered by your planOur prescription drug plans are administered by FutureScripts ,an independent pharmacy benefits management company who isresponsible for providing a network of participating pharmacies,administering benefits, conducting prior authorization reviews,and providing customer service. Y ou may need additional approval fromyour health plan before you receiveprescription drugsWhen using your prescription drug plan, it’s important to knowhow to find out what’s covered by your plan and whether thereare any guidelines that apply to those drugs. Our prescriptiondrug plans are designed to provide you with safe and affordableaccess to covered medications. This document will explainthe prior authorization process, age and quantity limits, anda number of other ways we support the safe prescription ofcovered medications. Q uantity limits apply to someprescription drugs** Please note that this document is applicable to the Standard Formulary, Select DrugFormulary, and Value Formulary. A ge limits apply to some prescription drugs Y our doctor may request coveragefor medications that are not covered byyour plan Y ou have a right to appeal a coveragedecision you disagree with H ow we work with FutureScriptsFormularyThe formulary is a list of drugs covered by your prescriptiondrug plan. If you’re not yet a member, you can visit ibx.com/rx toview the formulary guides or searchable tools. You can also call1-888-678-7012 to find out if a drug is included in your plan’sformulary. As a member, you can visit ibxpress.com to finddrugs on the formulary and view and manage your prescriptiondrug plan. The pharmacy tools and services available will helpyou to better understand your prescription drug coverage so youcan take full advantage of the cost-saving options availableto you.*Visit ibxpress.com to: Review your prescription records — what you spent, andwhen and where your prescriptions were filled Locate a network retail pharmacy near you Review your coverage and cost-sharing information Price a specific drug and compare savings with ageneric equivalent Access formulary information Check on drug-to-drug interactionsTo see the formulary status of a drug, or to find out if the drugrequires prior authorization, please refer to the formulary guideor searchable tool which can be found on your plan’s websiteibx.com/rx. You can also call FutureScripts at the number onthe back of your ID card if you want to find out whether a drug isincluded in your formulary.Prior AuthorizationPrior authorization is a requirement that your doctors obtainapproval from your health plan for coverage of, or payment for,your medication. Independence requires prior authorizationof certain covered drugs to confirm that the drug prescribed ismedically necessary and appropriate and is being prescribedaccording to Food and Drug Administration (FDA) guidelines.Some examples of drugs that require a prior authorization aredrugs to treat conditions like hemophilia, cancer, and hepatitisC. The approval criteria were developed and approved by thePharmacy and Therapeutics Committee, a group of doctors andpharmacists from the area.Using these approved criteria, clinical pharmacists evaluaterequests for these drugs based on clinical data, informationsubmitted by your prescribing doctor, and your availableprescription drug therapy history. Their evaluation may include areview of potential drug-drug interactions or contraindications,appropriate dosing and length of therapy, and utilization ofother drug therapies, if necessary.Without prior authorization, your prescription will not be coveredat the retail or mail-order pharmacy. The prior authorizationprocess may take up to two business days once completeinformation from the prescribing doctor has been received.Incomplete information will result in a delayed decision.Prior authorization approvals for some drugs may be limited to6 to 12 months. If the prior authorization for a drug is limited toa certain time frame, an expiration date will be given at the timethe approval is made. If the doctor wants you to continue thedrug therapy after the expiration date, a new prior authorizationrequest will need to be submitted and approved in order forcoverage to continue.

Age LimitsThe FDA has established specific procedures that governprescription prescribing practices. These rules are designedto prevent potential harm to patients and to confirm that themedication is being prescribed according to FDA guidelines.For example, some drugs are approved by the FDA only forindividuals age five and older, such as Zafirlukast (genericfor Accolate). The pharmacist’s computer provides up-todate information about FDA rules. If your prescription fallsoutside of the FDA guidelines, it will not be covered untilprior authorization is obtained. In addition, an age limit maybe applied when certain drugs are more likely to be used incertain age groups. For example, agents to treat Alzheimer’smay require prior authorization for use in young adults.The prescribing doctor may request consideration for priorauthorization of restricted medications when medicallynecessary. The approval criteria for this review were developedand approved by the Pharmacy and Therapeutics Committee.Contact your doctor to initiate the prior authorization process.To determine if a covered prescription drug prescribed for youhas an age limit, visit your plan’s website at ibx.com/rx or callFutureScripts at the number on the back of your ID card.Quantity limitsQuantity level limits are designed to allow a sufficient supply ofmedication based upon FDA-approved maximum daily doses,standard dosing, and/or length of therapy. We have severaldifferent types of quantity level limits that are explained indetail below. The purpose of these limits is to ensure safe andappropriate utilization. If you require more than the limit, yourdoctor will need to submit a prior authorization request. Note: Ifapplicable, quantity limits will apply if a formulary exception isapproved allowing coverage of a non-formulary drug.Quantity Over Time. This quantity limit is based on dosingguidelines over a rolling time period. For example, if adrug has a quantity limit over a 30-day time period and youwent to the pharmacy on January 1, 2018, for one of thesemedications, the computer system would have looked back 30days to December 2, 2017, to see how much medication wasdispensed. Examples of quantity limits over time are: uvaring 1 ring per 28 days N Ibandronate 150 mg (generic for Boniva ) 1 tablet per30 days Naratriptan (generic for Amerge ) nine 2.5 mg tabletsper 30 days, Sumatriptan (generic for Imitrex ) eighteen 50 mg tablets per 30 days Diabetic supplies such as blood glucose test strips 200strips per 30 days and lancets 200 lancets per 30 days.Maximum daily dose. This quantity limit is based on maximumnumber of units of the drug allowed per day. For example,if you went to a pharmacy for one of these medications, thecomputer system will ensure that the amount of medicationbeing requested per day does not exceed the maximum dailydose. Examples of maximum daily dose quantity limits are: sedative hypnotic drugs, such as zaleplon (generic forSonata ) 1 capsule per day) and zolpidem (generic forAmbien ) 1 tablet per day oral narcotic drugs, such as OxyContin 3 tablets perday, oxycodone/acetaminophen (generic for Percocet ) 6tablets per day proton pump inhibitor drugs, such as esomeprazole (genericfor Nexium ) 2 capsules per day and pantoprazole (genericfor Protonix ) 2 tablets per dayRefill too soon. This limit is in place to encourage appropriateutilization and minimize stockpiling of prescriptionmedications. Based on this edit, you are able to receive a refillof a prescription after 75% utilization. However, if the sameprescription is refilled every month at the 75% utilizationpoint, an excess supply will be accumulated. The plan will“look back” over a period of 180 days and calculate the totalday supply that has been dispensed.Day Supply Limit. This limit is based on the day supply andnot the quantity. However, quantity limits may apply as well.Day Supply Limits apply to some classes of drugs, such asnarcotics. If a quantity limit applies, you will be limited to themaximum daily dose for that drug. The following are examplesof drugs that have a day supply and a quantity limit: Headache agents, such as butalbital/aspirin or narcotics,such as oxycodone tablets– Day supply limit 5-day supply per 30 days– Quantity Limit 6 per 1 day– Maximum quantity allowed without priorauthorization 30 (6 per day x 5 days) Cough and cold products, such as hydrocodone/homatropine– Day supply limit 5-day supply per 30 days– Quantity Limit 30 ml per 1 day– Maximum quantity allowed without priorauthorization 150 ml (30 ml per day x 5 days)If your doctor wants to prescribe you a medication therapythat exceeds any of the utilization limits described above, yourdoctor must request a quantity limit override. You are requiredto contact the prescribing doctor to initiate the request.If the exception for a drug is limited to a certain time frame,an expiration date will be given at the time the approval ismade. If your doctor wants you to continue the drug therapy asrequested after the expiration date, a new request for a priorauthorization needs to be submitted and approved in order forcoverage to continue.To determine if a covered prescription drug prescribed foryou has a quantity limit or requires prior authorization, callFutureScripts at the phone number on the back of your ID cardor see the plan website at ibx.com/rx.