Pharmacy Management - Prior Authorization, Step Therapy and Quantity Limits (2017)

What are Pharmacy Management Programs?

Utilization Management

For certain prescription drugs, MVP Health Care has additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of utilization management tools are described below:

Prior Authorization (PA): We require you to get prior authorization for certain drugs. This means that your Primary Care Physician (PCP) or Specialist may ask for prior authorization from the plan. You will need to get approval from MVP Health Care before you fill your prescription. If they don't get approval, the drug may not be covered.

View the complete list of drugs that require a Prior Authorization for 2017.

Quantity Limits (QL): For certain drugs, MVP Health Care limits the amount of the drug that is covered per prescription or for a defined period of time. For example, MVP Health Care will provide up to 30 capsules per month for DEXILANT.

View the complete list of drugs that have a Quantity Limit for 2017.

Step Therapy (ST): In some cases, MVP Health Care requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

View the complete list of drugs that have a Step Therapy requirement for 2017.

Formulary Exceptions: If you learn that MVP does not cover your drug, you can ask your doctor to consider changing your medication to one that is on our Formulary. If your doctor does not feel that another drug is appropriate, you or your doctor can ask MVP Health Care to cover a Formulary excluded drug as a Formulary Exception by submitting a request to us. Also, if your medication has a quantity limit and the allowed quantity is not enough to treat your condition, you or your doctor may submit a Formulary Exception request asking MVP to cover a larger quantity for you. All requests submitted for Formulary Exception must be signed by a physician. They should also include documentation (chart notes) to support the request. Please note that MVP can not approve a Formulary Exception request for a Medicare excluded drug, only Formulary excluded drugs and drugs with a quantity limit will be considered.

You can also ask MVP to provide a higher level of coverage for your drug. For example, if your drug is contained in our Tier 4, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Tier 3 instead. This would lower the amount you must pay for your drug. All requests submitted for tier Exception must be signed by a physician. They should also include documentation (chart notes) to support the request.

Please note that if we grant your request to cover a drug that is not in our Formulary , you may not ask us to provide a higher level of coverage for that drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty Tier (Tier 5).

Coverage Determinations: If you are taking a medication that has a prior authorization, quantity limit, or step therapy requirement you may submit a request for a coverage determination. Generally, we will only approve your request for an Exception if the alternative drugs included on the Formulary, drugs in a lower tier, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. All requests for prior authorization must be submitted on a coverage determination request form that contains a physician's or prescribers signature, along with the supporting medical documentation identified in the Medicare Part D criteria. If you are asking for a Formulary, tiering, or quantity limit Exception you should submit a statement from your physician or prescriber supporting your request. Generally, we must make our decision within 72 hours of getting your physicians or prescribers supporting statement. You can request an expedited (fast) Exception if you or your physician or prescriber believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physicians or prescribers supporting statement. If your physician or prescriber does not provide us with the supporting information, we will wait up to 7 days to make our decision. If the supporting information is not received within 7 days, we will make the decision with the information that we have.

• Click here for our Coverage Determination Forms