Provider ManualPharmacyThis section outlines Commonwealth Care Alliance's pharmacy program, including details on our formulary and prior authorization. Also included is a description of Commonwealth Care Alliance's step therapy program, medication therapy management program, and mail order program. Commonwealth Care Alliance Pharmacy ProgramCommonwealth Care Alliance has contracted with informedRx/SXC a national pharmacy benefits management (PBM) company, to administer the pharmacy benefit on Commonwealth Care Alliance's behalf. Commonwealth Care Alliance has worked with its primary care partners to identify those community pharmacies in the neighborhoods of the primary care sites with whom Commonwealth Care Alliance's primary care providers have established relationships and members can access easily. In addition to many smaller independent pharmacies, Commonwealth Care Alliance's pharmacy network includes CVS, Rite Aid, Walgreen's and many others. For a complete and up-to-date listing of contracted pharmacies, please visit the pharmacy section of our website. FormularyCommonwealth Care Alliance has established a formulary that aims to provide prescribing clinicians with both a broad range of options for treatment while promoting the most cost-effective drug choices. Commonwealth Care Alliance will cover the drugs listed in the formulary as long as they are medically necessary. Click here to access the formulary list on our website. Prior AuthorizationCertain medications require prior authorization (prior approval) before a pharmacy can fill the prescription. Clinicians may request prior authorization by calling 1-800-626-0072. If prior authorization is not granted, the drug may not be covered. Click here to access the list of medications that require prior authorization. Information regarding pharmacy related grievances, appeals, and exceptions may be found here as well. Step Therapy ProgramIn support of efforts to provide members with the best medical care at a reasonable cost, Commonwealth Care Alliance has worked closely with health care professionals to develop step therapy programs. These programs initiate drug therapy for a medical condition with the most cost-effective and safest drug and step up through a sequence of alternative drug therapies as a preceding treatment option fails. Step therapy applies coverage rules at the pharmacy point of service (e.g. a first-line drug must be tried before a second-line drug can be used). If a prescription is written for a second-line drug and the step therapy rule was not met, the claim is rejected. A message is transmitted to the pharmacy indicating that the patient should be treated with the first-line drug before coverage of the second-line drug can be authorized. If a patient has been stabilized on a second-line prior to enrolling with Commonwealth Care Alliance, the new patient is allowed to remain on the second-line drug, per Commonwealth Care Alliance's transition policy. Click here to review the Commonwealth Care Alliance transition policy. Click here to access step therapy program information on our website. Mail Order ProgramIn addition to accessing medications from local retail pharmacies in the network, members and providers also have the ability to get extended day supply through mail for maintenance medications. It is anticipated that this will assist elders and their caregivers with receiving medication refills and greater quantity supply for those medications used on a prolonged basis. Medication Therapy Management ProgramCommonwealth Care Alliance offers medication therapy management (MTM) programs to members who take a number of different drugs, have chronic diseases (such as asthma, diabetes, or chronic heart failure), and have high annual drug costs. If members meet these three qualifications, they may be eligible for extra help in taking their medications, including extra education, and one-on-one meetings with clinical pharmacists in their local drug store. The MTM program was designed by doctors and pharmacists to help us provide the best possible care to the members by better managing their medications. Should members qualify for the MTM programs, they will be contacted. Last Updated 1/19/12 |
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