Frequently Asked Questions
We know that you may have questions regarding our prescription coverage. Here are some common questions and answers.
- What is a formulary?
- Why do the Coventry Health Care Health Plans need a formulary?
- How are drugs selected for the formulary?
- Are only the cheapest drugs on the formulary?
- Why would my doctor choose a medication that is not a preferred drug on the formulary for me?
- But what if my doctor thinks I should have a drug that is not a preferred drug on the formulary?
- What can I do to make the process work better for me and to keep my prescription costs low?
Prior Authorizations Questions
- Why do some drugs require prior authorization?
- How do I get a prior authorization?
- What is step therapy?
- What drugs are available through mail-order?
- Who determines the mail-order list?
- Where is my refill in the system?
- How much should my payment be?
- Who is eligible to use the mail-order prescription services?
Quantity Limits Questions
Prescription Drug Comparison Questions
What is a formulary?
A formulary is a list of medicines that a health plan covers. Coventry Health Care and its affiliated health plans use a committee of doctors and pharmacists to compare each drug’s safety, effectiveness and cost to determine which provide the most value. This committee is called the Pharmacy & Therapeutics (P&T) Committee.
Out of the hundreds of drugs available today, our formulary (preferred and nonpreferred) eliminates only a small percentage, while we have generally included several alternatives on the formulary. Our doctors and pharmacists nationwide keep up-to-date on the newest developments in medicine and continually improve the formulary based on the latest research.
Why do the Coventry Health Care Health Plans need a formulary?
Many people are not aware that the cost of prescription drugs is rising faster than any other portion of health care costs. Huge drug advertising costs are one reason for cost increases. Other reasons include an aging population that uses more drugs and the high cost of research and development for new drugs.
The alternative to a formulary would be to shift a greater portion of these rising costs to our members. Our formulary has been proven to ensure quality and, as an added benefit, control costs.
How are drugs selected for the formulary?
Coventry Health Care uses a committee of doctors and pharmacists (P&T Committee) to make these choices. First, we get input from local primary care doctors and specialists. Then our plans' Medical Directors and Pharmacists use this information to discuss with other Medical Directors and Pharmacists from our other health plans. We take all this local information and use it to help us choose the best drugs. Often, two drugs are equally safe and effective, but there can be major differences in their proven benefit to patients and in their costs.
Following an in-depth analysis, the committee adds safe, effective, affordable drugs to the formulary. While new medications may be added every three months, we try to remove drugs only once a year. In addition to the formulary, certain classes of drugs (such as those for cosmetic purposes or smoking cessation) may be excluded from your coverage.
Are only the cheapest drugs on the formulary?
No. In many cases, we have eliminated the least expensive drugs and have included several more expensive drugs in the same class. Given the rapid advances in medical science, sometimes the most effective medications may be more expensive than earlier classes of drugs. However, the most expensive drug is not always the best drug.
We always give first consideration to the safety and effectiveness of medications. There are many older, less expensive drugs that have been proven to save lives, while the newer more expensive drugs have not been shown to do this. But if several drugs are equivalent in terms of safety and effectiveness, then we will look at cost as a deciding factor.
Why would my doctor choose a medication that is not a preferred drug on the formulary for me?
There are many reasons why doctors write certain prescriptions. Doctors usually try to prescribe preferred medications on the formulary, but sometimes they write for a nonpreferred or nonformulary medication. Your doctor may have simply forgotten which medications are preferred or on the Coventry Health Care formulary. An updated formulary is mailed to all participating providers (and to any doctor who requests a copy) once a year. Any changes are published in a quarterly provider newsletter and on our website. Doctors may prescribe new medications if they have seen a recent advertisement, or because a representative of a pharmaceutical company visited them recently. Sometimes doctors prescribe a medication because they have free samples in the office, without realizing that the medication is not a preferred drug or on our formulary.
Also, doctors may write for medications that they have used for a long time, even when newer, better medications come on the market. By continually reviewing current medical literature, we ensure that safe, cost-effective medications are covered on our formulary.
But what if my doctor thinks I should have a drug that is not a preferred drug on the formulary?
Your doctor is able to freely prescribe any medication that he/she believes you should be taking. You are free to have any of these prescriptions filled and to pay for the medicines yourself. We do not require your doctor to prescribe only preferred formulary medications.
If your employer has selected a benefit where nonpreferred formulary medications are not covered, your doctor can request a formulary exception. However, unless your doctor can show that a nonpreferred formulary medication is medically necessary to treat your condition and that a preferred formulary medication is either not safe or not effective; the cost of the nonpreferred formulary medication is not covered under your plan. We review your doctor’s request and if it is not approved, you may still choose to have the prescription filled and pay the full cost of the nonpreferred formulary drug.
If your employer has selected a three-tier prescription benefit, nonpreferred formulary drugs are covered at a higher copayment. In some states, if your physician deems that a nonpreferred formulary drug is medically necessary to treat your condition and that a formulary medication is either not safe or not effective; your doctor can still request a formulary exception. We review your doctor’s request and if it is approved, the prescription will be covered at the applicable generic or brand-name copayment. If the request is not approved, you may still choose to have the prescription filled and pay the nonpreferred formulary copayment. Contact Member Services at the number on your member ID card to find out if you have a thee-tier benefit.
What can I do to make the process work better for me and to keep my prescription costs low?
Before your doctor prescribes a medication, be sure to ask if it is a preferred drug on our formulary. If it is not, ask your doctor if there is an equivalent preferred formulary medication that would work as well for you. In most cases, the physician has two or more medications from which to choose. We have given our participating doctors a list of preferred formulary drugs. Each time the formulary is updated, we send a list of changes to our participating doctors as well. We also have a member version of the list available, which you can take to your appointment to assure that you will get a preferred formulary drug. If you do not have a copy of the member formulary, you can get one by calling Member Services at the number on your member ID card. Most of our formulary changes during the year are additions, but the most current version is available on this website and can be downloaded.
Prior Authorizations Questions
Why do some drugs require prior authorization?
Some drugs require prior authorization because our doctors feel that they should only be used after other medications have been tried first. Others are drugs that have only been used for very limited medical problems. In deciding what drugs to put on the Prior Authorization List, our committee of doctors and pharmacists consider the safety, effectiveness and cost of the drugs as well as the medical literature on the subject.
How do I get a prior authorization?
To get a prior authorization, the member’s doctor should call, fax or send a letter to the health plan for review and approval if appropriate. The member’s physician may call Member Services at the toll-free number on the member’s ID card to request prior authorization.
What is step therapy?
Step therapy is a form of prior authorization based on previous prescriptions used by the member. Drugs designated as stepped therapy will require prior authorization if the member’s pharmacy claims history does not indicate that a specified drug or drugs have been previously tried by the member when the pharmacist transmits a prescription claim.
How is my Copay determined?
The copay is determined by the employer’s benefit plan. Many employers have three-tier copay benefits, where the member pays the lowest copay for a preferred drug, a moderate copay for a preferred formulary brand-name drug, and a higher copay for a nonpreferred formulary drug. Some employee benefit plans do not cover nonpreferred formulary drugs.
What drugs are available through mail-order?
Plan-approved maintenance medications are available through mail-order if the member’s employer has purchased a mail-order benefit. Some of the drugs that are excluded include non-maintenance medications, all controlled substances, warfarin (Coumadin) and methotrexate tablets (Rheumatrex). Members may call the toll-free member service number shown on their ID card to find out if specific medications are covered through mail-order.
Who determines the mail-order list?
The health plan determines which drugs will be on the mail-order list. The mail-order list is a list of certain maintenance medications that are appropriate for long-term use for the majority of members. Not all medications prescribed for a long-term condition are considered maintenance medications. So we do not include them on the mail-order list. The purpose of the mail-order list is to have a consistent and convenient way to help members follow their medication treatment plans. At the same time we want to limit the risk of adverse effects, waste or abuse. We will not make individual exceptions to the standard mail-order list.
Where is my refill in the system?
To check on the status of your order, visit My Online Services and select “Prescription Benefits” under “Wellness Tools.” You’ll find a link to Medco on the lower-left side of the page. You can also call Member Services at the toll-free number shown on your ID card.
How much should my payment be?
The member’s pharmacy rider explains the copay structure for the pharmacy benefit. Members may also call member services at the toll-free number listed on their ID card to get this information.
Who is eligible to use the mail-order prescription services?
Each individual employer group chooses whether or not to offer its employees mail-order prescription services as part of their prescription drug benefits. To verify whether this option is available to you, please check with your employer or call the toll-free number shown on your ID card.
Quantity Limits Questions
Why are there quantity limits?
Quantity limits are set on medications for different reasons. Many commonly used once-daily drugs have limits since these drugs are proven to be safe and effective when taken once daily. Secondly, the different strengths of many of these drugs cost the same amount of money. For these two reasons, taking two pills daily instead of one doubles the cost of therapy without necessarily improving the benefit. Other drugs are on the list as a safeguard to make sure that members do not receive a prescription for a quantity that exceeds recommended limits. Limits are set because some medications have either a maximum limit recommended by the FDA or a maximum dose.
How are quantity limits determined?
The limits are reviewed and determined by clinical staff, pharmacy directors, and/or the Pharmacy & Therapeutics Committee. The quantity limits are based on FDA-approved dosing schedules and the medical literature related to the particular drug.
What is the exception process?
The physician’s office can contact the health plan where the pharmacy department and/or medical staff review the medical information provided by the physician and determine if an exception is appropriate. The health plan's Pharmacy Department then puts an authorization into the pharmacy system if the request is approved.
Prescription Drug Comparison Questions
Where can I find reputable consumer information on drug comparisons?
My Rx Choices® helps you quickly find lower-priced prescription options to consider with your doctors. Through My Rx Choices®, you have access to personalized, real-time pricing information that allows you to easily compare the cost of your current maintenance medication with generic and brand-name options, both at retail and through mail-order. You have access to Consumer Reports Best Buy DrugsTM† recommendations, including information on the effectiveness and safety of prescription drugs.
† Consumers Union, the nonprofit publisher of Consumer Reports® magazine, and Medco have a non-exclusive arrangement that provides consumers with independent, unbiased information on the effectiveness and safety of prescription drugs. This information is prepared solely by Consumer Reports Best Buy Drugs™, a public education project administered by Consumers Union. The content and recommendations contained in the reports may not represent the opinions or recommendations of Medco, its independent Pharmacy and Therapeutics Committee, or plan sponsors. There is no financial arrangement between the two companies, or between Consumers Union and the Medco client that sent you this message. The drug information we provide is not a substitute for consultation with your doctor, but may help you talk to your doctor about which medicines may be right for you.