The management of outpatient prescription medications is an integral part of the medical management program and is necessary to improve the health and well being of our members. Provider and member involvement is critical to the success of the pharmacy program. Therefore, in order to help your patients get the most out of their pharmacy benefit, please be cognizant of the following guidelines when prescribing:

·      Follow national standards of care guidelines such as the NIH Asthma Guidelines and JNC VII Hypertension Guidelines.

·      Prescribe generic medications whenever a therapeutic equivalent medication
is available.

·      Evaluate medication profiles for appropriateness and duplication of therapy.

Coverage Limitations
The following is a list of non-covered (excluded) medications and/or categories:

Generic Medications

Generic drugs are equally effective and generally less costly than the brand medication. Their use can contribute to cost-effective therapy. Generic drugs must be dispensed by the pharmacist when a drug therapeutically equivalent to a brand name drug is available. Exceptions to the mandatory generic policy, when therapeutically equivalent options are available, require medical justification. An exception request should be filled out on a Drug Evaluation Review (DER) form and FDA Medwatch form.

• Accu-Chek Meter Form
• Bayer Meter Form
• Enteral Nutrition Form
• Injectable-Infusion Form
• Oral-Solid Drug Evaluation Review Form
• Synagis Form