Medical Mutual - Health Plans for Life

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

Medical Mutual and Express Scripts 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 Medical Mutual’s prescription formulary, pharmaceutical education, prior authorization, clinical services, and home delivery practices that we hope will enhance your interactions with Medical Mutual regarding pharmaceutical therapy.

Please note: Express Scripts recently merged with Medco Health Solutions, Inc. The combined company will now be known as Express Scripts. You will continue to see the Medco name on certain communications for now

For more information

If you have questions regarding coverage management programs, please call Express Scripts Coverage Management at 800.753.2851, 8 a.m. to 9 p.m. EST, Monday through Friday. For general questions regarding Express Scripts' programs, please contact the Physician Service Center at 800.211.1456, 8 a.m. to 8 p.m EST, Monday through Friday.


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Topic  

Prescription Formulary

Medical Mutual members participate in an open formulary program that helps manage prescription drug benefit costs. The formulary, known as The Basic Formulary, is managed by Express Scripts 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 Express Scripts' policies are medically sound and support your patient's health. The committee reviews and evaluates each medication on the Basic 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 Basic Formulary.

Click here to see 2015 Formulary Changes.

Click here to see 2015 Formulary Overview.

Click here to see 2014 Monthly Formulary Changes.


Coverage Management (Prior Authorization, Step Therapy, and Quantity Limits)

Coverage Management

Overview of Coverage Management Programs

Coverage Management Updates

Prior Authorization

The Medical Mutual 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 Medical Mutual members, such as:

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:

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:

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. Express Scripts 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.
  • Our pharmacy benefit manager, Express Scripts, now offers an online prior authorization portal for providers called ExpressPAth. Using ExpressPAth you are able to initiate new prior authorization requests, complete existing prior authorization requests, or check the status of previously submitted prior authorization requests. To use this tool, access the ExpressPAth Prior Authorization Portal for Providers.
  • Express Scripts 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®(10 and 20 mg - see below for 2.5 & 5 mg), Muse®, and Staxyn®. 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 Medical Mutual for coverage approval

Drug Class

Drugs in Class

Fax Forms

Acthar

Acthar Gel

Acthar Fax Form

Adempas

Adempas

Adempas Fax Form

Afinitor

Afinitor

Anabolic Steriods-Androgens

Anadrol-50, Android, Androxy, Delatestryl, Depo-Testosterone, Methitest, Nandrolon Decanoate injection, Oxandrin, Straint, Tesamone, Testopel, Testred, Winstrol

Anabolic Steroid/ Androgens Fax Form

Angiotensin II Receptor Antagonists

Atacand, Atacand HCT, Avalide, Avapro, Benicar, Benicar HCT, Edarbi, Edarbyclor, Teveten, Teveten HCT

Angiotensin II Receptor Fax Form

Antidepressants Therapy

Celexa, Cymbalta, Effexor XR, Lexapro, Paxil, Paxil CR, Pexeva, Pristiq, Prozac, Prozac Weekly, Remeron, Viibryd, Wellbutrin SR, Wellbutrin XR, Zoloft,

Antidepressants Therapy Fax Form

Anti-Influenza Therapy

Relenza, Tamiflu

Anti-Influenza Therapy Fax Form

Antiemetic Agents

Aloxi, Anzemet, Granisol, Kytril, Sancuso, Zofran

Antiemetic Agents Fax Form

Antifungal Agents

Diflucan, Lamisil, Sporanox

Antifungal Agents Fax Form

Antipsoriatic Agents

Enbrel, Stelara

Enbrel Fax Form
Stelara Fax Form

Apokyn

Apokyn

Apokyn Fax Form

Asthma

Xolair

Xolair Fax Form

Atopic Dermatitis

Elidel, Protopic

Atopic Dermatitis Fax Form

Benlysta

Benlysta

Benlysta Fax Form

Beta2 Agonist/Corticosteroid Inhalers

Advair Diskus, Advair HFA, Breo Ellipta

Beta2 Agonist/Corticosteroid Inhalers Fax Form

Bisphosphonates

Actonel (certain strengths), Atelvia

Bisphosphonate Fax Form

Botulinum Toxin

Botox, Botox Cosmetic, Dysport, Myobloc, Xeomin

Botulinum Toxin Fax Form

Breast Cancer - Primary Prevention

Raloxifene, Tamoxifen

Breast Cancer - Primary Prevention Fax Form

Caprelsa

Caprelsa

Cialis

Cialis (2.5 & 5 MG)

Cialis Fax Form

Cometriq

Cometriq

Contraceptive Agents

All contraceptive agents not being prescribed for contraceptive purposes

Contraceptive Fax Form

COX-2 Inhibitors

Celebrex

COX-2 Inhibitors Fax Form

Daliresp

Daliresp

Daliresp Fax Form

Emend

Emend

Emend Fax Form

Erivedge

Erivedge

Erythroid Stimulants

Aranesp, EPO, Epogen, Procrit

Erythroid Stimulants Fax Form

Esbriet

Esbriet

Fentanyl

Abstral, Actiq, Fentanyl Powder, Fentora, Onsolis

Fentanyl Fax Form

Firazyr

Firazyr

Firazyr Fax Form

Gaucher Disease Agents

Cerezyme, Vpriv, Zavesca

Gaucher Fax Form

Gilenya

Gilenya

Gilenya Fax Form

Gilotrif

Gilotrif

Gleevec

Gleevec

Growth Hormones

Accretropin, Genotropin, Geref, Humatrope, Increlex, Iplex, Miniquick, Nordiflex, Norditropin, Nuspin, Nutropin, Omnitrope, Protropin, Saizen, Serostim, Tev-Tropin, Valtropin, Zorbtive

Growth Hormone Fax Form

HAE (Hereditary Angioedema) Agents

Berinert, Cinryze, Kalbitor

Berinert Fax Form, Cinryze Fax Form, Kalbitor Fax Form.

Harvoni

Harvoni

Hepatitis C Drugs

Olysio, Sovaldi

Olysio Fax Form, Sovaldi Fax Form

Hetlioz

Hetlioz

Hetlioz Fax Form

Hypnotic Agents

Ambien, Ambien CR, Edluar, Intermezzo, Lunesta, Rozerem, Silenor, Sonata, Zolpimist

Hypnotic Fax Form

Hysingla ER

Hysingla ER

Hysingla ER Fax Form

Iclusig

Iclusig

Imbruvica

Imbruvica

Incivek

Incivek

Incivek Fax Form

Inlyta

Inlyta

Intranasal Steroids

Beconase AQ, Dymista, Flonase, Nasacort AQ, Nasonex, Omnaris, Rhinocort Aqua, Veramyst, Zetonna

Intranasal Fax Form

Jakafi

Jakafi

Kalydeco

Kalydeco

Kalydeco Fax Form

Korlym

Korlym

Korlym Fax Form

Lynparza

Lynparza

Lynparza Fax Form

Mekinist

Mekinist

Migraine Agents

Alsuma, Amerge, Axert, Frova, Imitrex, Imitrex STATdose Pen, Imitrex STATdose System, Maxalt, Maxalt MLT, Migranal, Relpax, Sumavel, Treximet, Zomig, Zomig-ZMT

Migraine Fax Form

Multiple Sclerosis Agents

Avonex, Betaseron, Copaxone, Extavia, Rebif

Avonex Fax Form, Betaseron Fax Form, Copaxone Fax Form, Extavia Fax Form, Rebif Fax Form

Myeloid Stimulants

Leukine, Neulasta, Neumega, Neupogen

Myeloid Stimulant Fax Form, Neulasta Fax Form, Neumega Fax Form

Nexavar

Nexavar

Non-Sedating Antihistamines

Clarinex, Clarinex-D, Levocertirizine, Xyzal

Non-Sedating Antihistamines Fax Form

Northera

Northera

Northera Fax Form

Nplate

Nplate

Nplate Fax Form

Nuedexta

Nuedexta

Nuedexta Fax Form

Ofev

Ofev

Opsumit

Opsumit

Opsumit Fax Form

Orenitram

Orenitram

Plegridy

Plegridy

Plegridy Fax Form

Pomalyst

Pomalyst

Promacta

Promacta

Promacta Fax Form

Proton Pump Inhibitors

Aciphex, Dexilant, Iansoprazole, Omeprazole-sodium bicarbonate, Prevacid, Prilosec packets, Protonix, Zegerid

Proton Pump Inhibitors Fax Form

Provigil/Nuvigil

Nuvigil, Provigil

Provigil/Nuvigil Fax Form

Pulmonary Arterial Hypertension

Adcirca, Flolan, Letairis, Remodulin, Revatio, Tracleer, Ventavis

Pulmonary Arterial Hypertension Fax Form

Revlimid

Revlimid

Rheumatological Agents

Actemra, Arava, Cimzia, Enbrel, Humira, Kineret, Orencia, Otezla, Remicade, Rituxan, Simponi, Xeljanz

Actemra Fax Form, Actemra IV Fax Form, Arava Fax Form, Cimzia Fax Form, Enbrel Fax Form, Humira Fax Form, Kineret Fax Form, Orencia Fax Form, Otezla Fax Form, Remicade Fax Form, Rituxan Fax Form, Simponi Fax Form, Xeljanz Fax Form

Solodyn

Solodyn

Solodyn Fax Form

Sprycel

Sprycel

Sprycel Fax Form

Stivarga

Stivarga

Sublingual Immunotherapy

Grastek, Oralair, Ragwitek

Grastek Fax Form, Oralair Fax Form, Ragwitek Fax Form

Sutent

Sutent

Synagis

Synagis

Tafinlar

Tafinlar

Tarceva

Tarceva

Tarceva Fax Form

Tasigna

Tasigna

Tazarotene Cream

Tazorac

Tazorac Fax Form

Tecfidera

Tecfidera

Tecfidera Fax Form

Temodar

Temodar

Thalomid

Thalomid

Tretinoin

Avita, Retin-A

Tretinoin Fax Form

Tykerb

Tykerb

Tysabri

Tysabri

Tysabri Fax Form

Victrelis

Victrelis

Victrelis Fax Form

Vidaza

Vidaza/Dacogen

Vidaza Fax Form

Viekira

Viekira

Viekira Fax Form

Votrient

Votrient

Xalkori

Xalkori

Xeloda

Xeloda

Xyrem

Xyrem

Xyrem Fax Form

Zelboraf

Zelboraf

Zohydro ER

Zohydro ER

Zohydro Fax Form

Zykadia

Zykadia

Zykadia Fax Form

Zytiga

Zytiga


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. Express Scripts 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.


Pharmaceutical Education

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

  • Physician practice summaries
  • Patent expiration notifications
  • Formulary education programs
  • Newsletters, e-mails, website articles, and more

Each year Express Scripts pharmacists make over 1 million contacts (faxes and phone calls) to physicians to define Medical Mutual’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, Express Scripts will obtain the physician’s authorization to dispense the originally prescribed drug.


Mail Order Pharmacy

  • Medical Mutual members may have a mail order pharmacy 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.

Find a Provider

Maximize your cost savings and avoid unexpected charges by finding providers in the SuperMed® network.

Find a Provider

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