Here are some answers to frequently asked questions about our members' pharmacy benefits.
With Quality Care Dosing, we electronically check prescription medications before they’re filled to ensure that the quantity and dosage is consistent with the recommendations of the Food and Drug Administration (FDA) and others.
Prescriptions that do not meet recommendations may be modified in two ways:
A Quality Care Dosing override can be submitted if you believe it’s clinically necessary for an exception to the guidelines.
The patient's prescriber can request a formulary exception by calling Clinical Pharmacy Operations at 1-800-366-7778 or by using the Massachusetts Standard Form for Medication Prior Authorization Requests. You’ll need to explain the medical necessity of frequency and/or dose size.
Your patient can continue to take his or her medication as you prescribed it unless otherwise noted in medical policy 621, Quality Care Dosing (QCD) Guidelines.
We consider a variety of factors, including: whether a drug is a generic or a brand name; whether the drug is unique; whether there are clinically appropriate alternatives to a drug; the drug's cost-effectiveness; and the drug’s FDA indications.
Our Pharmacy and Therapeutics (P&T) Committee, comprised of practicing physicians and pharmacists throughout the state, acts as an advisory committee for our pharmacy program. The program obtains recommendations from the P&T Committee and various other sources regarding many aspects of the drugs. We review this input and ultimately make the final tier decision.
As with all drugs that are excluded from coverage, there is a Formulary Exception request process. This allows a prescriber to request coverage for a non-covered drug when a patient is unable to use any covered alternative for a specific medical reason. If your request for an exception for a non-covered drug is approved, the copayment will be at the third-tier level (at tier 4 for members with a 4-tier benefit).
Request a formulary exception by calling Clinical Pharmacy Operations at 1-800-366-7778 or using the Massachusetts Standard Form for Medication Prior Authorization Requests.