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Frequently Asked Questions

Select Drug Program®

What is the FutureScripts® Pharmacy and Therapeutics Committee?

Am I required to prescribe only medications on your formulary?

How do I find a participating network pharmacy?

What is the mail-order program?

What are the procedures for safe prescribing?

When should I obtain Prior Authorization?

What are age and gender limits?

What are the quantity level limits?

How do I request an exception to an age, gender, and quantity limits?

How do I appeal a decision (coverage or limits)?

What is an urgent temporary supply?

How do I request a formulary copay exception (specific to Select Drug Program members only)?

How frequently does the formulary change?

What if I believe a medication should be considered for the formulary?

What is the FutureScripts® Pharmacy and Therapeutics Committee?
The FutureScripts Pharmacy and Therapeutics Committee was formed to oversee pharmacy policies and procedures and to promote the selection of clinically safe, clinically effective, and economically advantageous medications for our members. The committee is made up of plan medical directors, plan pharmacists, practicing physicians, and practicing pharmacists. The physicians practice in a variety of specialties.

The committee meets every other month and may amend the Select Drug Program® formulary and Standard Drug Program List of Preferred Drugs quarterly — in January, April, July, and October. Physicians are typically notified of these changes through our monthly Partners in Health Update.

Download the Formulary Changes.

Am I required to prescribe only medications on your formulary?
You can prescribe any covered medication, regardless of whether the drug is on the formulary or not. The formulary is a list of preferred medications intended to help members receive pharmaceutical coverage at a lower out-of-pocket expense. Be aware that medications on this list may be subject to the member’s contract exclusions and other pharmacy edits.

How do I find a participating network pharmacy?
Members should take their prescription identification cards to pharmacies that participate in the FutureScripts network. FutureScripts is a national company that specializes in drug benefit management. More than 56,000 participating retail pharmacies in the U.S. recognize and accept FutureScripts prescription identification cards, including large chains and many neighborhood pharmacies. When members are traveling in the U.S., participating FutureScripts pharmacies will accept their cards and dispense medications based on their prescription benefit plan.

To help members locate a participating pharmacy, call FutureScripts at 1-888-678-7012.

What is the mail-order program?
A Standard, Select, Deductible/Coinsurance (DE/PA), or Deductible/Copayment (NJ) Drug Program member with a mail-order program benefit may choose to receive certain prescriptions by mail for convenience and cost-effectiveness. Under this program, you can write two separate prescriptions for the member. One prescription is for an initial supply, which the member may fill immediately at a pharmacy. The second prescription is for the mail-order service and should be written for a 90-day supply of medication. The member receives information on how to fill mail-order prescriptions upon enrollment.

What are the procedures for safe prescribing?
The Pharmacy Services Department monitors the effectiveness and safety of drugs and drug prescribing patterns. Several procedures, some of which are described under the prior authorization section, have been established to support safe prescribing patterns.

When should I obtain prior authorization?
AmeriHealth requires prior authorization of certain covered drugs that have been approved by the FDA for specific medical conditions. The approval criteria was developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee and is based on information from the FDA and manufacturers, medical literature, actively practicing consultant physicians, and appropriate external organizations.

Clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the prescribing physician, and available prescription drug history. The clinical pharmacists determine whether there are drug interactions or contraindications, dosing and length of therapy are appropriate, and clinical options are evaluated.

If the request cannot be approved by applying established review criteria (see grid in the link below), a medical director will review the request. Without prior authorization, the member’s prescription will not be covered at a retail or mail-order pharmacy.

The prior authorization process may take up to two (2) working days once complete information from the prescribing physician has been received. Incomplete information will result in a delayed decision.

View the list of drugs requiring prior authorization and instructions for requesting prior authorization.

What are age and gender limits?
Age and gender limits are designed to prevent potential harm to members and promote appropriate utilization. The approval criteria is based on information from the FDA, medical literature, actively practicing consultant physicians and pharmacists, and appropriate external organizations, and are endorsed by the FutureScripts Pharmacy and Therapeutics Committee. For example, some drugs are only approved by the FDA for individuals age 14 and older, such as Cipro®, or if prescribed only for females, such as prenatal vitamins.

Our systems are linked to participating pharmacies’ systems, which provide up-to-date information regarding age and gender limits. If the member’s prescription does not meet the FDA age and gender guidelines, it will not be covered unless an exception is obtained. To request an age or gender limit exception, the physician may submit appropriate documentation of medical necessity for review.

What are quantity level limits?
Quantity level limits are designed to allow a sufficient supply of medication based on FDA recommendations and endorsement from the FutureScripts Pharmacy and Therapeutics Committee. The first type of quantity edit is based on a 30-day supply of a medication per fill. Examples of quantity level limits per fill include Avonex® (1 kit [4 injections]); Betaseron® (15 vials); Copaxone® (32 vials); Rebif® (12 injections); sedative-hypnotic drugs such as Sonata® (14 capsules) and Ambien CR™ (14 tablets); and oral narcotic drugs such as OxyContin® (90 units), Percodan® (180 units), and Percocet (180 units). If the prescription exceeds the quantity limit, the pharmacist will fill for the allowed supply and then the member must follow up with his or her physician regarding future prescriptions. The prescribing physician may request a quantity limit override if the member’s therapy requires a larger daily dose of medication.

Another type of quantity edit is based on FDA dosing guidelines over a rolling 30-day period. Quantity level limits per a rolling 30-day period apply to migraine medications, such as Amerge® (9 tablets 2.5 mg), Imitrex® (36 tablets 50 mg), Maxalt® (12 tablets 10 mg), Migranal® (8 units 4 mg nasal spray), Stadol NS® (4 units 10 mg), and Zomig® (9 tablets 5 mg). In addition, some fertility agents (if covered under the group contract) are included in the rolling edits, such as Fertinex®, Follistim®, Gonal F®, Humegon®, Pergonal®, and Repronex® (all at 60 ampules).

If the quantity of medication prescribed exceeds the quantity level limit, the prescribing physician must submit supporting information to the Pharmacy Services Department that demonstrates the need for an increased quantity. The member should contact the prescribing physician to initiate a request for a quantity override. The purpose of these edits is to make certain that these drugs are used as prescribed.

To determine whether a covered prescription drug has an age, gender, or quantity level limit, please contact Provider Services for HMO members and Member Services for PPO members.

Another type of quantity level limit is the “Refill Too Soon” edit. If a member has used less then 75 percent of the total supply, the claim will be rejected at the pharmacy. This edit helps ensure that medication is being taken in accordance with the prescribed dose and frequency of administration.

How do I request an exception to an age, gender, or quantity limit?
To request an age, gender, or quantity limit exception, the physician may submit appropriate documentation of medical necessity for review. You should fax requests for an override to 1-888-671-5285.

How do I appeal a decision (coverage or limits)?
If a request for prior authorization or formulary coverage for a non-formulary medication is denied, you can appeal on behalf of the member. Both you and the member will receive written notification of a denial, which will include the appropriate telephone number and address to direct an appeal. In all cases, you need to be involved in the appeal process to provide the required medically necessary information for the basis of the appeal.

What is an urgent temporary supply?
We are aware that there may be times when an urgent supply is necessary for a medication requiring prior authorization or utilization edit exception. A one-time, 96-hour urgent supply may be obtained for these medications with the exception of:

  • products for which manufacturer’s packaging precludes dispensing a 96-hour supply (e.g., Enbrel®, topical retinoid products, antihemophilic factor, Nimotop®, and Depo-Provera®);
  • drugs not covered under the member's pharmacy benefit;
  • drugs for erectile dysfunction.

The retail pharmacy will receive an online message advising them to call for assistance in processing the claim for the urgent supply of medication. The member is not charged cost-sharing for this supply.

The prescriber will be contacted the next business day to obtain information needed to initiate the prior authorization or exception process. The Pharmacy Services Department will process the request upon receipt of complete information (see prior authorization requirements). Processing of a 96-hour urgent supply request is not a guarantee of approval of the prior authorization or exception request.

How do I request a formulary copay exception (specific to Select Drug Program members only)?
Physicians may request coverage of a non-formulary medication at the formulary copayment when all formulary alternatives have been exhausted or when there are contraindications to using the formulary alternatives. The physician should complete the Non-Formulary Exception Request, providing detail to support use of the non-formulary medication, and fax the request to 215-241-3073 or 1-888-671-5285.

If the non-formulary request is approved, the drug will be processed at the appropriate formulary benefit copayment. If the request is denied, the member and physician will receive a denial letter that explains the appeal process. The member may still receive benefits for the covered non-formulary drug at the non-formulary copayment or non-formulary coinsurance.

How frequently does the formulary change?
The Committee meets every other month and may amend the Select Drug Program formulary and Standard Drug Program List of Preferred Drugs quarterly — in January, April, July, and October. Physicians are typically notified of these changes through our monthly Partners in Health Update.

Download the most recent Formulary Changes document.

What if I believe a medication should be considered for the formulary?
You may petition for the inclusion of a medication or dosage to be included on the formulary. To do so, make your requests, in writing, to the Senior Vice President of Pharmacy Services at 1901 Market Street, Philadelphia, PA 19103.