Generic Program Exception Process

Some of our members have a Dispense as Written (DAW) generic program as part of their prescription drug benefits. This means if a member has a prescription for a particular brand-name drug that is also available in generic form, he or she will pay more for that brand-name drug if he or she opts to fill it instead of the generic version. If you feel that the generic version is not appropriate for a particular member, please complete this Generic Program Exception Form to request an exception detailing why this member must have the brand-name drug over the generic version. This exception process is only applicable to members whose benefits are subject to the rules under the ACA/essential health benefits for prescription drug coverage.

Nonspecialty Drug Prior Authorization Program

We require prior approval for drugs included in our prior authorization program for most members. 

CoverMyMeds

Our pharmacy benefit manager has partnered with CoverMyMeds to offer free electronic prior authorization (ePA) services to all providers and their staff. ePA helps prescribers and pharmacies quickly find, complete and submit prior authorization (PA) requests.

You can use CoverMyMeds to:

• Submit the request electronically
• Quickly find the correct PA request form for your patient’s plan
• Receive real-time plan specific clinical guideline questions (where applicable)
• Complete PA requests started by pharmacies
• Easily manage follow-up for all your requests and patients
• Check status of ePA requests submitted

To Get Started all you need to do is register for a free account or log into your existing CoverMyMeds account.

Create an account by:

• Selecting "Create an Account".
• Filling out required basic account information:
  • Full name
  • Email address
  • Office type
  • Username and password

Prior authorizations are also accepted via phone and fax. To request a prior authorization for non-specialty drugs, call the Prior Authorization department at 833-494-2987.

PreCheck MyScript

PreCheck MyScript^® is a real-time benefits check tool embedded within the EMRworkflow. It displays lower-cost alternatives for prescriptions, which medications require prior authorizations (PAs), and more.

• Average savings for physicians and office staff for each PA that is avoided is $41.
• Average time savings for physicians and office staff for each PA that is avoided is 50 minutes

PreCheck MyScript seamlessly integrates with many common EMR platforms, with additional integrations ongoing.

Quality Management Program

We limit the amount we cover for medications included in the quantity management program for many members. We cover higher quantities for some medications, when medical necessity is documented. 

Step Therapy Program

We require a generic or over-the-counter alternative trial before we cover medications included in the step therapy program for most members. We waive this requirement when medical necessity is documented