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Rx Benefit Management

Medical Mutual’s guide to prescription formulary, pharmaceutical education, prior authorization, clinical services, and home delivery practices

Medical Mutual and Medco Health Solutions, Inc. have developed a comprehensive, valued, and affordable prescription drug benefit that meets the prescription therapy needs of all its members. Included below is an overview of Medical Mutual’s pharmaceutical education, prior authorization, clinical services, and home delivery practices that we hope will enhance and abbreviate your interactions with Medical Mutual regarding pharmaceutical therapy.

For more information

If you have questions regarding Medco's coverage management programs, please call Medco Coverage Management at 800/753-2851, 8:00 a.m. to 9:00 p.m. EST, Monday through Friday. For general questions regarding Medco's programs, please contact the Physician Service Center at 800/211-1456, 8:00 a.m. to 8:00 p.m. EST, Monday through Friday.

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Prescription Formulary

Medical Mutual of Ohio members participate in an open formulary program that helps manage prescription drug benefit costs. The formulary, known as Rx Selections, is managed by Medco Health Solutions, Inc. and contains more than 700 medications. An independent Pharmacy & Therapeutics committee of physicians and pharmacists has been formed to assist in creating the formulary and to confirm that Medco's policies are medically sound and support your patient's health. The committee reviews and evaluates each medication on the Rx Selections formulary for safety and efficacy and ensures choices are available in all therapeutic categories.

You can help make sure your patients have access to affordable prescription coverage by prescribing with cost and coverage in mind. Access the Medco Interactive Rx Selections Formulary.

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Prior Authorization

The Medical Mutual plan requires that some medications be preapproved or receive “prior authorization” for coverage. These medications may fall under one of the following prior authorization programs:

Traditional Prior Authorization

Traditional prior authorization requires a prescribing physician to obtain pre-approval before prescribing certain medications to Medical Mutual members, such as:

Smart Prior Authorization

Smart prior authorization uses an automated process called Smart Rules™ to determine if your patient qualifies for coverage. Using factors such as your patients’ medical and drug history, age, or sex, Smart Rules can often eliminate the need for a coverage review. Some medications that may be approved under Smart Rules are:

Authorizations for Additional Quantities of Medication

Coverage for some medications is approved for limited quantities within a specified time frame. A coverage review is needed to request additional quantities. Some of these medications include:

Coverage review process

  • If your patient or a pharmacist requests your help in completing a coverage review, please call 800/753-2851 to initiate the review. Medco will fax a form for you to fill out and return. Please note that a timely response is important. If medication is needed before approval, your patient will have to pay the full cost of the medication out-of-pocket, which is reimbursable (less co-pay) if the prescription is approved.
  • Medco Health will send you and your patient a letter that confirms or denies coverage approval (usually within 2 business days of receiving the necessary information).
  • If coverage is approved, your patient will pay the normal co-payment for the medication. If coverage is not approved, your patient will be responsible for the full cost of the medication. Your patient has the right to appeal the decision. Information on the appeal process will be included in the letter you receive.

Please Note:

A coverage review is not available for medications that treat erectile dysfunction, such as Viagra®, Edex®, Levitra®, Caverject®, Cialis®, and Muse®. Your patients must pay the full cost of any additional quantities of medication that you prescribe beyond the allowable amount.

Drugs that may require Prior Authorization

Click on the Drug Class to see the Criteria In Use by Medical Mutual for coverage approval

Online Provider Services

Electronic Referrals

For PCPs to issue referrals for members enrolled in the SuperMed Select, SuperMed HMO and HMO Health Ohio products.

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Precertification

Hospitals may submit certifications for inpatient elective, urgent or emergency admissions for medical, surgical, or obstetric cases.

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Drug Class

Drugs in Class

Fax Forms

Actiq/Fentora

Actiq, Fentora

Actiq/Fentora Fax Form

Angiotensin II Receptor Blockers (A2RBs)

Atacand, Atacand HCT, Avalide, Avapro, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, Hyzaar, Micardis, Micardis HCT, Teveten, Teveten HCT

Angiotensin Fax Form

Antidepressants Therapy

Prozac, Prozac Weekly, Paxil, Paxil CR, Celexa, Zoloft, Lexapro, Wellbutrin, Wellbutrin XR, SR, Effexor, Effexor XR, Cymbalta

Antidepressants Therapy Fax Form

Anti-Influenza Therapy

Relenza, Tamiflu

Anti-Influenza Therapy Fax Form

Antiemetic Agents

Anzemet, Kytril, Zofran

Antiemetic Agents Fax Form

Antipsoriatic Agents

Amevive, Raptiva, Enbrel

Amevive & Raptiva Fax Form
Enbrel Fax Form

Antifungal Agents

Diflucan, Lamisil, Sporanox

Antifungal Agents Fax Form

Apokyn

Apokyn

Apokyn Fax Form

Asthma

Xolair

Asthma Fax Form

Atopic Dermatitis

Elidel, Protopic

Atopic Dermatitis Fax Form

Botulinum Toxin

Botox, Myobloc

Botulinum Toxin Fax Form

Calcium Channel Blockers

Norvasc, Cardene SR, Plendil, Procardia XL,
Adalat CC, Dynacirc CR, Sular

Calcium Channel Blockers Fax Form

Contraceptive Agents

All contraceptive agents not being prescribed for contraceptive purposes

Contraceptive Fax Form

COX-2 Inhibitors

Celebrex

COX-2 Inhibitors Fax Form

CNS Stimulants

Adderall, Adderall XR, Focalin, Focalin XR, Dexedrine, Dexedrine Spansules, Dextrostat, Desoxyn, Ritalin, Ritalin SR, Ritalin LA, Metadate CD, Concerta, Methylin ER, Strattera, Vynanse

CNS Stimulants Fax Form

Emend

Emend

Emend Fax Form

Erythroid Stimulants

EPO, Epogen, Procrit, Aranesp

Erythroid Stimulants Fax Form

Growth Hormones

Genotropin, Geref, Humatrope, Norditropin, Nutropin, Protropin, Serostim, Saizen, Tev-Tropin

Growth Hormone Fax Form

Hypnotic Agents

Ambien CR, Lunesta, Sonata, Rozerem

Hypnotic Fax Form

Iressa

Iressa

Iressa Fax Form

Leukotriene Receptor Antagonists/Formation Inhibitors

Accolate, Singulair, Zyflo

Leukotriene Fax Form

Migraine Agents

Amerge, Axert, Frova, Imitrex, Imitrex STATdose Pen, Imitrex STATdose System, Maxalt, Migranal, Relpax, Zomig, Zomig-ZMT

Migraine Fax Form

Myeloid Stimulants

Neupogen, Leukine

Myeloid Stimulant Fax Form

Neulasta

Neulasta

Neulasta Fax Form

Neumega

Neumega

Neumega Fax Form

Pemoline

Pemoline

Pemoline Fax Form

Proton Pump Inhibitors

Aciphex, Prevacid, Protonix

Proton Pump Inhibitors Fax Form

Provigil

Provigil

Provigil Fax Form

Pulmonary Arterial Hypertension

Ventavis, Revatio, Tracleer

Pulmonary Arterial Hypertension Fax Form

Rheumatological Agents

Arava, Enbrel, Humira, Kineret, Remicade, Orencia, Rituxan

Rheumatological Agents Fax Form

RSV Agents

Synagis

RSV Fax Form

Tarceva

Tarceva

Tarceva Fax Form

Tazarotene Cream

Tazorac

Tazorac Fax Form

Tretinoin

Avita, Retin-A

Tretinoin Fax Form

Vidaza

Vidaza

Vidaza Fax Form

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Clinical Services

Help improve compliance, reduce risk of hospitalization

RationalMed® can help you protect your patient’s health and prevent unnecessary hospitalizations caused by improper use of prescription drugs. RationalMed is a sophisticated, outcomes-driven system that combines medical and prescription drug data and looks for: potential drug interactions; drug reactions based on medical history; drug duplication due to multiple prescribers; duration issues; and over/underutilization problems. Provider alert letters are issued to you when the system identifies potential problems related to medical therapies. Medco has observed a 65 percent increase in the number of physicians who adjusted their prescriptions based on a RationalMed notice, versus standard drug utilization review programs.

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Pharmaceutical Education

Medco Health also provides physicians with educational opportunities about the safety, efficacy, and cost savings offered by generic alternatives. These education programs include:

  • Generics First®—a continuing medical education program for prescribers
  • Physician practice summaries
  • Patent expiration notifications
  • Formulary education programs
  • Newsletters, e-mails, website articles, and more

Each year Medco pharmacists make over 1 million contacts (faxes and phone calls) to physicians to define the Medical Mutual plan’s preferred generic and brand-name equivalents, and to promote substitution. However, if a member does not want to consent to a physician-authorized interchange, or if the member experiences a tolerance issue with the new drug, Medco will obtain the physician’s authorization to dispense the originally prescribed drug.

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Medco Home Delivery Pharmacy®

  • Medical Mutual members may have a home delivery benefit. Please remember that quantities can be written for up to a 90-day supply plus refills up to a year, as appropriate.
  • Prescribing a generic drug, or permitting generic substitution when clinically appropriate, can reduce prescription drug costs as well as your patient's out-of-pocket copayments, often saving $10-$15 per prescription.

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