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Rx Benefit Management

Consumers Life’s guide to prescription formulary, pharmaceutical education, prior authorization, clinical services, and home delivery practices

Consumers Life and Medco Health Solutions, Inc. have developed a comprehensive, valued, and affordable prescription drug benefit that meets the prescription therapy needs of all its members. Included below is an overview of Consumers Life’s prescription formulary, pharmaceutical education, prior authorization, clinical services, and home delivery practices that we hope will enhance and abbreviate your interactions with Consumers Life regarding pharmaceutical therapy.

Prescription Formulary
Prior Authorization
Clinical Services
Pharmaceutical Education
Home Delivery Pharmacy

For more information

If you have questions regarding Medco's coverage management programs, please call Medco Coverage Management at 800/753-2851, 8 a.m. to 9 p.m. EST, Monday through Friday. For general questions regarding Medco's programs, please contact the Physician Service Center at 800/211-1456, 8 a.m. to 8 p.m EST, Monday through Friday.

Prescription Formulary

Consumers Life members participate in an open formulary program that helps manage prescription drug benefit costs. The formulary, known as Rx Selections, is managed by Medco Health Solutions, Inc. and contains more than 700 medications. An independent Pharmacy & Therapeutics committee of physicians and pharmacists has been formed to assist in creating the formulary and to confirm that Medco's policies are medically sound and support your patient's health. The committee reviews and evaluates each medication on the Rx Selections formulary for safety and efficacy and ensures choices are available in all therapeutic categories.

You can help make sure your patients have access to affordable prescription coverage by prescribing with cost and coverage in mind. Access the Medco interactive Rx Selections Formulary.

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Prior Authorization

The Consumers Life plan requires that some medications be preapproved or receive “prior authorization” for coverage. These medications may fall under one of the following prior authorization programs:

Traditional Prior Authorization

Traditional prior authorization requires a prescribing physician to obtain pre-approval before prescribing certain medications to Consumers Life members, such as:

Xolair® (omalizumab)
Growth hormones
Oral contraceptives
Medications that have cosmetic uses

Smart Prior Authorization

Smart prior authorization uses an automated process called Smart Rules™ to determine if your patient qualifies for coverage. Using factors such as your patients’ medical and drug history, age, or sex, Smart Rules can often eliminate the need for a coverage review. Some medications that may be approved under Smart Rules are:

COX-2 inhibitor drugs
Leukotriene receptor antagonists/formation inhibitors
Central nervous system (CNS) stimulant drugs
Selected hypertension medications/Angiotensin II Receptor Blockers

Authorizations for Additional Quantities of Medication

Coverage for some medications is approved for limited quantities within a specified time frame. A coverage review is needed to request additional quantities. Some of these medications include:

Selected migraine medications
Selected antifungal medications

Coverage review process

If your patient or a pharmacist requests your help in completing a coverage review, please call 800/753-2851 to initiate the review. Medco will fax a form for you to fill out and return. Please note that a timely response is important. If medication is needed before approval, your patient will have to pay the full cost of the medication out-of-pocket, which is reimbursable (less co-pay) if the prescription is approved.
Medco Health will send you and your patient a letter that confirms or denies coverage approval (usually within 2 business days of receiving the necessary information).
If coverage is approved, your patient will pay the normal co-payment for the medication. If coverage is not approved, your patient will be responsible for the full cost of the medication. Your patient has the right to appeal the decision. Information on the appeal process will be included in the letter you receive.

Please Note:

A coverage review is not available for medications that treat erectile dysfunction, such as Viagra®, Edex®, Levitra®, Caverject®, Cialis®, and Muse®. Your patients must pay the full cost of any additional quantities of medication that you prescribe beyond the allowable amount.

Drugs that may require Prior Authorization

Click on the Drug Class to see the Criteria In Use by Consumers Life for coverage approval


Drug Class	Drugs in Class	Fax Forms
Actiq/Fentora	Actiq, Fentora	Actiq/Fentora Fax Form
Angiotensin II Receptor Blockers (A2RBs)	Atacand, Atacand HCT, Avalide, Avapro, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, Hyzaar, Micardis, Micardis HCT, Teveten, Teveten HCT	Angiotensin Fax Form
Antidepressants Therapy	Prozac, Prozac Weekly, Paxil, Paxil CR, Celexa, Zoloft, Lexapro, Wellbutrin, Wellbutrin XR, SR, Effexor, Effexor XR, Cymbalta	Antidepressants Therapy Fax Form
Anti-Influenza Therapy	Relenza, Tamiflu	Anti-Influenza Therapy Fax Form
Antiemetic Agents	Anzemet, Kytril, Zofran	Antiemetic Agents Fax Form
Antipsoriatic Agents	Amevive, Raptiva, Enbrel	Amevive & Raptiva Fax Form Enbrel Fax Form
Antifungal Agents	Diflucan, Lamisil, Sporanox	Antifungal Agents Fax Form
Apokyn	Apokyn	Apokyn Fax Form
Asthma	Xolair	Asthma Fax Form
Atopic Dermatitis	Elidel, Protopic	Atopic Dermatitis Fax Form
Botulinum Toxin	Botox, Myobloc	Botulinum Toxin Fax Form
Cimzia	Cimzia	Cimzia Fax Form
Contraceptive Agents	All contraceptive agents not being prescribed for contraceptive purposes	Contraceptive Fax Form
COX-2 Inhibitors	Celebrex	COX-2 Inhibitors Fax Form
CNS Stimulants	Adderall, Adderall XR, Focalin, Focalin XR, Dexedrine, Dexedrine Spansules, Dextrostat, Desoxyn, Ritalin, Ritalin SR, Ritalin LA, Metadate CD, Concerta, Methylin ER, Strattera, Vynanse	CNS Stimulants Fax Form
Emend	Emend	Emend Fax Form
Erythroid Stimulants	EPO, Epogen, Procrit, Aranesp	Erythroid Stimulants Fax Form
Growth Hormones	Genotropin, Geref, Humatrope, Norditropin, Nutropin, Protropin, Serostim, Saizen, Tev-Tropin	Growth Hormone Fax Form
Hypnotic Agents	Ambien CR, Lunesta, Sonata, Rozerem	Hypnotic Fax Form
Iressa	Iressa	Iressa Fax Form
Leukotriene Receptor Antagonists/Formation Inhibitors	Accolate, Singulair, Zyflo	Leukotriene Fax Form
Migraine Agents	Amerge, Axert, Frova, Imitrex, Imitrex STATdose Pen, Imitrex STATdose System, Maxalt, Migranal, Relpax, Zomig, Zomig-ZMT	Migraine Fax Form
Myeloid Stimulants	Neupogen, Leukine	Myeloid Stimulant Fax Form
Neulasta	Neulasta	Neulasta Fax Form
Neumega	Neumega	Neumega Fax Form
Non-Sedating Antihistamines	"Clarinex, Clarinex Redi-tabs, Clarinex-D, Allegra, Allegra-D, Allegra 12, 24hr, Xyzal, Xyzal Susp	Non-Sedating Antihistamines Fax Form
Pemoline	Pemoline	Pemoline Fax Form
Proton Pump Inhibitors	Aciphex, Prevacid, Protonix	Proton Pump Inhibitors Fax Form
Provigil	Provigil	Provigil Fax Form
Pulmonary Arterial Hypertension	Ventavis, Revatio, Tracleer	Pulmonary Arterial Hypertension Fax Form
Rheumatological Agents	Arava, Enbrel, Humira, Kineret, Remicade, Orencia, Rituxan	Rheumatological Agents Fax Form
RSV Agents	Synagis	RSV Fax Form
Tarceva	Tarceva	Tarceva Fax Form
Tazarotene Cream	Tazorac	Tazorac Fax Form
Tretinoin	Avita, Retin-A	Tretinoin Fax Form
Vidaza	Vidaza	Vidaza Fax Form

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Clinical Services

Help improve compliance, reduce risk of hospitalization

RationalMed® can help you protect your patient’s health and prevent unnecessary hospitalizations caused by improper use of prescription drugs. RationalMed is a sophisticated, outcomes-driven system that combines medical and prescription drug data and looks for: potential drug interactions; drug reactions based on medical history; drug duplication due to multiple prescribers; duration issues; and over/underutilization problems. Provider alert letters are issued to you when the system identifies potential problems related to medical therapies. Medco has observed a 65 percent increase in the number of physicians who adjusted their prescriptions based on a RationalMed notice, versus standard drug utilization review programs.

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Pharmaceutical Education

Medco Health also provides physicians with educational opportunities about the safety, efficacy, and cost savings offered by generic alternatives. These education programs include:

Generics First®—a continuing medical education program for prescribers
Physician practice summaries
Patent expiration notifications
Formulary education programs
Newsletters, e-mails, website articles, and more

Each year Medco pharmacists make over 1 million contacts (faxes and phone calls) to physicians to define the Consumers Life plan’s preferred generic and brand-name equivalents, and to promote substitution. However, if a member does not want to consent to a physician-authorized interchange, or if the member experiences a tolerance issue with the new drug, Medco will obtain the physician’s authorization to dispense the originally prescribed drug.

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Medco Home Delivery Pharmacy®

Consumers Life members may have a home delivery benefit. Please remember that quantities can be written for up to a 90-day supply plus refills up to a year, as appropriate.
Prescribing a generic drug, or permitting generic substitution when clinically appropriate, can reduce prescription drug costs as well as your patient's out-of-pocket copayments, often saving $10-$15 per prescription.

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