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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.

For more information

Regarding Coverage Management Programs

Call 800.753.2851
Express Scripts' Coverage Management is available Monday - Friday, 8 a.m. to 9 p.m.

General Questions About Express Scripts Programs

Call 800.211.1456
Express Scripts' Prescriber Service Center is available Monday - Friday, 8 a.m. to 8 p.m.

Rx Benefits Overview

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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 and using the following tools.

2017 Comprehensive Basic Plus Formulary (Commercial Plans)

2017 Comprehensive Basic Plus Formulary (MHS Plans)

2017 Comprehensive High Performance Plus Formulary (Metal Plans)

2017 National Preferred Formulary

2017 National Preferred Formulary, Preferred Drug List Exclusions

Monthly Formulary Changes

Additions to Step Therapy Program (Coverage Management)

Medicare

The information found on this page does not apply to Medicare. To view the Medicare formulary or coverage management criteria (e.g. prior authorization, step therapy) visit https://www.medmutual.com/For-Medicare/Our-Medicare-Plans/Medicare-Advantage-Plans-with-Prescription-Drug-MAPD/Important-Plan-Information.aspx.

Medicare Part D Formulary

Coverage Management (Prior Authorization)

Prior Authorization

The Medical Mutual plan requires that some medications be preapproved or receive “prior authorization” for coverage.

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.

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
Addyi	Addyi	Addyi Fax Form
Afinitor	Afinitor	Afinitor Fax Form
Alecensa	Alecensa	Alecensa Fax Form
Alpha-1 Proteinase Inhibitors	Prolastin-C, Aralast NP, Zemaira, Glassia
Ampyra	Ampyra	Ampyra Fax Form
Androgens-Anabolic Steriods	Androl-50, Danazol, Nandrolone, Oxandrin	Danazol Fax, Select Androgens and Anabolic Steroids Fax
Androgens-Testosterone	Androgel® 1.62% gel and Androgel 1% gel, Android, Methitest, Testred, Android, Methitest, Testred (methyltestosterone), Androxy, Androxy (fluoxymesterone), Aveed, Aveed (testosterone undecanoate), Axiron™ (testosterone topical solution), Delatestryl, Delatestryl (testosterone enanthate), Depo-Testosterone, Depo®-Testosterone (testosterone cypionate), Fortesta™ (testosterone 2% topical gel), Natesto™ (testosterone nasal gel), Striant® (testosterone buccal system), Testim® (testosterone 1% gel), Testopel, Testopel (testosterone) pellet, testosterone 1% gel (brand products), Testosterone gel (generic products), Vogelxo™ (testosterone 1% gel)	Oral and Injectable Testosterone Fax
Antipsoriatic Agents	Otezla, Stelara, Taltz	Otezla HPF Fax Form, Stelara Fax Form, Taltz Fax Form
Apokyn	Apokyn	Apokyn Fax Form
Atopic Dermatitis	Elidel, Eucrisa, Protopic	Atopic Dermatitis Fax Form
Austedo	Austedo
Auvi-Q	Auvi-Q	Auvi-Q Fax Form
Benlysta	Benlysta	Benlysta Fax Form
Bosulif	Bosulif	Bosulif 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	Caprelsa Fax Form
Cholbam	Cholbam	Cholbam Fax Form
Cialis	Cialis (2.5 & 5 MG)	Cialis Fax Form
Cinqair	Cinqair	Cinqair Fax Form
Colony Stimulating Factors	Leukine, Neulasta, Neupogen, Zarxio	Colony Stimulating Factor Fax, Neulasta Fax
Cometriq and Cabometyx	Cabometyx, Cometriq	Cometriq and Cabometyx Fax form
Conditionally Excluded Drugs for High Performance Plus Formulary (effective 1/1/17)	Addyi, Contrave, Jublia/Ciclodan 8%, Novarel, Osphena	Addyi Fax Form, Contrave Fax, Jublia/Ciclodan Fax, Novarel Fax, Osphena Fax
Contraceptive Agents	All contraceptive agents not being prescribed for contraceptive purposes
Corlanor	Corlanor	Corlanor Fax Form
Cosentyx	Cosentyx	Cosentyx Fax Form
Cotellic	Cotellic	Cotellic Fax Form
Cuprimine	Cuprimine	Cuprimine Fax Form
Dacogen	Dacogen/Vidaza	Dacogen Fax Form
Daliresp	Daliresp	Daliresp Fax Form
Diclegis	Diclegis	Diclegis Fax Form
Dupixent	Dupixent	Dupixent Fax Form
Emflaza	Emflaza	Emflaza Fax Form
Entresto	Entresto	Entresto Fax Form
Entyvio	Entyvio	Entyvio Fax Form
Erivedge	Erivedge	Erivedge Fax
Erythroid Stimulants	Aranesp, EPO, Epogen, Mircera, Procrit	Erythroid Stimulants Fax Form, Mircera Fax Form
Esbriet	Esbriet	Esbriet Fax
Exondys 51	Exondys 51	Exondys 51 Fax Form
Farydak	Farydak	Farydak Fax Form
Gaucher Disease Agents	Cerdelga, Cerezyme, Elelyso, Vpriv, Zavesca	Gaucher Fax Form
Gilotrif	Gilotrif	Gilotrif Fax
Gleevec	Gleevec, Imatinib	Gleevec Fax Form
Global Prior Authorization	Arestin, Arymo ER, Eucrisa, Rhofade, Soliqua, Trulance, Xermelo, Xultrophy, Yosprala, Zurampic	Global Prior Authorization Fax Form
Growth Hormones	Accretropin, Genotropin, Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton, Geref, Humatrope, Increlex, Iplex, Miniquick, Nordiflex, Norditropin, Nuspin, Nutropin, Omnitrope, Protropin, Saizen, Serostim, Tev-Tropin, Valtropin, Zorbtive	Growth Hormone Fax Form for Basic/Basic Plus and National Preferred Formulary
HAE (Hereditary Angioedema) Agents	Berinert, Cinryze, Firazyr, Kalbitor, Ruconest	Berinert Fax Form, Cinryze Fax Form, Firazyr Fax Form, Kalbitor Fax Form, Ruconest Fax Form
Hepatitis C	Daklinza, Epclusa, Harvoni, Olysio, Sovaldi, Technivie, Viekira, Zepatier	Epclusa Fax Form, Olysio Fax Form, Viekira Fax Form, Zepatier Fax Form
Hetlioz	Hetlioz	Hetlioz Fax Form
Ibrance	Ibrance	Ibrance Fax Form
Iclusig	Iclusig	Iclusig Fax Form
Ilaris	Ilaris	Ilaris Fax Form
Imbruvica	Imbruvica	Imbruvica Fax Form
Immune Globulins (IV)	Immune Globulins (IV)	IVIG Fax Form
Immune Globulins (SC)	Immune Globulins (SC)	IVIG/SCIG Fax
Infertility - Follitropins	Bravelle, Follistim AQ	Follitropins Fax Form
Ingrezza	Ingrezza
Inlyta	Inlyta	Inlyta Fax Form
Intrarosa	Intrarosa	Intrarosa Fax Form
Iressa	Iressa	Iressa Fax Form
Jakafi	Jakafi	Jakafi Fax Form
Juxtapid	Juxtapid	Juxtapid Fax
Kalydeco	Kalydeco	Kalydeco Fax Form
Kisqali	Kisqali, Kisqali Femara Co-Pack	Kisqali Fax Form
Korlym	Korlym	Korlym Fax Form
Lemtrada	Lemtrada	Lemtrada Fax Form
Lenvima	Lenvima	Lenvima Fax Form
Leuprolide LA	Eligard, Lupaneta, Lupron Depot, Lupron Depot-Ped	Eligard Fax Form, Lupron Fax Form
Lidoderm	Lidoderm or Lidocaine Patch	Lidoderm Fax Form
Lonsurf	Lonsurf	Lonsurf Fax Form
Lynparza	Lynparza	Lynparza Fax Form
Medical Device	V-Go Disposable Insulin Delivery Device
Mekinist	Mekinist	Mekinist Fax
Multiple Sclerosis	Aubagio, Copaxone/Glatopa, Gilenya, Interferon Beta Injectables, Tecfidera, Zinbryta	Aubagio Fax Form, Copaxone/Glatopa Fax Form, Gilenya Fax Form, Interferon Beta Injectables Fax Form, Tecfidera Fax Form, Zinbryta Fax
Myalept	Myalept	Myalept Fax
Natpara	Natpara	Natpara Fax Form
Nexavar	Nexavar	Nexavar Fax Form
Ninlaro	Ninlaro	Ninlaro Fax Form
Northera	Northera	Northera Fax Form
Nplate	Nplate	Nplate Fax Form
Nucala	Nucala	Nucala Fax Form
Nuedexta	Nuedexta	Nuedexta Fax Form
Nulojix	Nulojix	Nulojix Fax Form
Nuplazid	Nuplazid	Nuplazid Fax Form
Ocaliva	Ocaliva	Ocaliva Fax Form
Ocrevus	Ocrevus	Ocrevus Fax Form
Odomzo	Odomzo	Odomzo Fax Form
Ofev	Ofev	Ofev Fax
Opioid Induced Constipation	Amitiza, Movantik, Relistor, Symproic	Amitiza Fax Form, Movantik Fax Form, Relistor Fax Form, Symproic Fax Form
Orencia	Orencia	Orencia Basic/NPF Fax Form, Orencia HPF Fax Form
Orkambi	Orkambi	Orkambi Fax Forms
Osphena	Osphena	Osphena Fax Form
Pegylated Interferons	PegIntron	Pegylated Interferons Fax Form
Pomalyst	Pomalyst	Pomalyst Fax
Praluent	Praluent	PCSK-9 Fax
Promacta	Promacta	Promacta Fax Form
Provigil/Nuvigil	Nuvigil, Provigil	Provigil/Nuvigil Fax Form
Pulmonary Arterial Hypertension	Adempas, Opsumit, Orenitram, Uptravi	Orenitram Fax Form, Pulmonary Arterial Hypertension, Uptravi Fax Form
Repatha	Repatha	PCSK-9 Fax
Restasis	Restasis	Restasis Fax Form
Revlimid	Revlimid	Revlimid Fax Form
Rheumatological Agents	Actemra IV, Actemra SC, Cimzia, Enbrel, Humira, Kineret, Remicade, Rituxan, Simponi, Xeljanz and Xeljanz XR	Actemra IV Fax Form, Actemra SC Fax Form, Cimzia Basic/NPF Fax Form, Cimzia HPF Fax Form, Enbrel Basic/NPF Fax Form, Humira Fax Form, Kineret Fax Form, Remicade Fax Form, Rituxan Fax Form, Simponi Fax Form, Xeljanz Basic/NPF Fax Form , Xeljanz HPF Fax Form
Rubraca	Rubraca	Rubraca Fax Form
Siliq	Siliq	Siliq Fax Form
Spinraza	Spinraza	Spinraza Fax Form
Sprycel	Sprycel	Sprycel Fax Form
Stivarga	Stivarga	Stivarga Fax Form
Strensiq	Strensiq	Strensiq
Sublingual Immunotherapy	Grastek, Oralair, Ragwitek	Grastek Fax Form, Oralair Fax Form, Ragwitek Fax Form
Sutent	Sutent	Sutent Fax Form
Sylatron	Sylatron	Sylatron Fax Form
Synagis	Synagis	Synagis Fax
Syprine	Syprine	Syprine Fax Form
Tafinlar	Tafinlar	Tafinlar Fax
Tagrisso	Tagrisso
Tarceva	Tarceva	Tarceva Fax Form
Targretin	Targretin gel	Targretin Fax Form
Tasigna	Tasigna	Tasigna Fax Form
Tazarotene Cream		Tazorac Fax Form
Tecentriq	Tecentriq	Tecentriq Fax Form
Temodar	Temodar	Temodar Fax Form
Thalomid	Thalomid	Thalomid Fax Form
Transmucosal Fentanyl	Abstral, Actiq, Fentora, Lazanda, Subsys	Fentanyl Fax Form
Tretinoin	Avita, Retin-A	Tretinoin Fax Form
Tykerb	Tykerb	Tykerb Fax
Tysabri	Tysabri	Tysabri Fax Form
Venclexta	Venclexta	Venclexta Fax Form
Vidaza	Vidaza/Dacogen	Vidaza Fax Form
Votrient	Votrient	Votrient Fax Form
Xalkori	Xalkori	Xalkori Fax
Xeloda	Xeloda	Xeloda Fax Form
Xenazine	Xenazine	Xenazine Fax Form
Xiidra	Xiidra	Xiidra Fax
Xolair	Xolair	Xolair Fax
Xtandi	Xtandi	Xtandi Fax
Xuriden and Vistogard	Vistogard, Xuriden	Xuriden and Vistogard Fax Form
Xyrem	Xyrem	Xyrem Fax Form
Zaltrap	Zaltrap	Zaltrap Fax Form
Zejula	Zejula
Zelboraf	Zelboraf	Zelboraf Fax
Zydelig	Zydelig	Zydelig Fax Form
Zykadia	Zykadia	Zykadia Fax Form
Zytiga	Zytiga

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Coverage Management (Step Therapy)

Step Therapy

The Medical Mutual plan requires that a trial of another medication or agent be used before approval of the targeted medication. If no recent history of the preferred medication or agent is found, a prior authorization is required.

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.

Drugs that May Require a Trial of Another Agent (Step Therapy) or 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
Acne - Other Topical Products	Branded Topical Prescription Acne Products	Acne Topical Fax
Acne - Topical Cleansers	Branded Prescription Acne Cleansers	Acne- Cleansers Fax
Acne - Topical Kits	Branded Prescription Acne Kits	Acne Kit Fax
Angiotensin II Receptor Antagonists	Atacand, Atacand HCT, Avalide, Avapro, Cozaar, Diovan, Diovan HCT, Edarbi, Edarbyclor, Exforge, Hyzaar, Micardis, Micardis HCT, Teveten, Teveten HCT	Angiotensin II Receptor Fax Form
Antidepressants Therapy	Aplenzin, Brintellix, Brisdelle, Budeprion SR, Budeprion XL, Celexa, Cymbalta, Desvenlafaxine extended-release tablets (brand product), Desvenlafaxine fumarate extended-release tablets (brand product), Effexor XR, Fetzima, Fluoxetine 60 mg tablets, Forfivo XL, Khedezla, Lexapro, Luvox CR, Paxil, Paxil CR, Pexeva, Pristiq, Prozac, Prozac Weekly, Remeron, Sarafem, Savella, Venlafaxine extended-release tablets (Brand Product), Viibryd, Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zoloft	Antidepressants Therapy Fax Form
Antifungal - topical	Ciclodan 8% Kit, CNL 8 Nail Kit, Jublia, Kerydin, Pedipirox-4 Nail Kit, Penlac	Antifungal Fax
Atopic Dermatitis	Elidel, Eucrisa, Protopic	Atopic Dermatitis Fax Form
Attention Deficit Hyperactivity Disorder	Addderall XR, Aptensio XR, Concerta, Daytrana, Dexedrine Spansules, Dyanavel XR, Focalin XR, Metadate CD, QuiliChew ER and IR, Ritalin LA and SR, Vyvanse	ADHD Fax
Beta-Blocker	Branded Beta-blockers and Beta-blocker Combinations	Beta Blocker Fax
Beta2 Agonists (short-acting) Inhalers PST	Proventil HFA, Xopenex HFA	Beta2 Agonists (short-acting) Inhalers PST
Bisphosphonates	Actonel, Atelvia, Binosto, Boniva, Fosamax, Fosamax Plus D	Bisphosphonate Fax Form
Contraceptives (Oral and Patch)	Branded Contraceptives	Contraceptive Fax
Diabetes - Glucagon-Like Peptide-1 (GLP-1) Agonists	Tanzeum, Trulicity, Victoza	GLP-1 Agonists Fax Form
Diabetes - Insulin (other)	Novolin 70/30, Novolin N, Novolin R	Insulin (other) Fax Form
Diabetes - Insulin (rapid-acting)	Apidra, Apidra Solostar, Novolog, Novolog Mix 70/30	Insulin (rapid-acting) Fax Form
Diabetes - Metformin ER	Fortamet, Glucophage XR, Glumetza, Metformin ER	Metformin Fax Form
Diabetes - SGLT-2	Farxiga, Invokana, Invokamet, Jardiance, Xigduo XR, Synjardy	SGLT-2 Fax
Diabetes - SGLT-2/DPP-4	Glyxambi	Glyxambi Fax
Diabetic Test Strips	Bayer (Contour, Contour Next, and Breeze 2) , Nipro (TRUEtrack, TRUEtest, TRUEmetrix, Health Alliance, Liberty) , Roche (e.g., Accu-Chek Active, Accu-Chek Advantage, Accu-Chek Aviva, Accu-Chek Aviva Plus, Accu-Chek Comfort Curve, Accu-Chek Compact, Accu-Chek Compact Plus, Accu-Chek Smartview)	Diabetic Test Strips Fax Form
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors	Jentadueto, Kazano, Nesina, Tradjenta	DPP-4 Inhibitors Fax Form
Epinephrine auto-injectors	Epinephrine auto-injector, Epipen, Epipen Jr.	Epinephrine auto-injectors Fax Form
Erectile Dysfunction	Levitra, Staxyn, Stendra	Erectile Dysfunction Fax Form
Erythroid Stimulants PSM	Aranesp, Epogen	Erythroid Stimulants Fax Form
Gabapentin	Gralise, Horizant, Lyrica, Neurontin	Gabapentin Fax
Glaucoma Ophthalmic Alpha Adrenergic Agonist	Alphagan P 0.15%, Iopidine 0.5% and 1%	Alpha Adrenergic Agonist Fax
Glaucoma Ophthalmic Beta-Adrenergic Blocker	Istalol, Betagan, Timoptic, Timoptic XE	Beta-Adrenergic Blocker Fax
Glaucoma Ophthalmic Carbonic Anhydrase Inhibitor	Trusopt	Carbonic Anhydrase Inhibitor Fax
Glaucoma Ophthalmic Combination Product	Cosopt	Combination Product Fax
Growth Hormone	Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton	Growth Hormone Basic/NPF Formulary Fax
Hepatitis C Drugs (effective 1/1/17)	Harvoni, Sovaldi, Daklinza, Technivie, Epclusa, Viekira (XR), Olysio, Zepatier
HMG-CoA Reductase Inhibitors	Altoprev, Caduet, Crestor, Livalo, Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Vytorin, Zocor	HMG-CoA (statin) Fax Form
Hypnotics	Ambien, Ambien CR, Belsomra, Edular, Intermezzo, Lunesta, Rozerem, Silenor, Sonata, Zolpimist	Hypnotics Fax Form
Infertility - Gonadotropin Releasing Hormone (GnRH) Antagonists	Cetrotide	Ganirelix Fax Form, GnRH Antagonists Fax Form
Inflammatory Bowel	Asacol, Asacol HD, Delzicol, Dipentum	Inflammatory Bowel Fax Form
Inflammatory Care Basic/Basic Plus and National Preferred	Actemra, Cimzia, Cosentyx, Enbrel, Humira, Kineret, Orencia, Otezla, Simponi, Stelara, Taltz, Xeljanz, Xeljanz XR
Inflammatory Care High Performance Plus	Actemra, Cimzia, Cosentyx, Enbrel, Humira, Kineret, Orencia, Otezla, Simponi, Stelara, Taltz, Xeljanz, Xeljanz XR
Inhaled Corticosteroids	Flovent HFA, Flovent Diskus, Alvesco, Aerospan, Arnuity Ellipta	Inhaled Corticosteroids Fax Form
Intranasal Steroids	Beconase AQ, Dymista, Nasacort AQ, Nasonex, Omnaris, Qnasi, Rhinocort Aqua, Veramyst, Zetonna	Intranasal Fax Form
Methotrexate Injection	Otrexup, Rasuvo	Methotrexate Injection Fax Form
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, Zinbryta	Avonex Fax Form, Betaseron Fax Form, Copaxone Fax Form, Extavia Fax Form, Rebif Fax Form
Nonsteroidal Anti-inflammatory Drug (NSAID)	Branded NSAIDs and topical diclofenac gel	NSAID Fax
Oncology Care Value Program	Nexavar, Afinitor, Avinitor Disperz, Lenvima, Xtandi	Afinitor OCV fax, Lenvima OCV Fax, Nexavar OCV Fax, Xtandi OCV Fax
Ophthalmic NSAIDS	Acular, Acular LS, Acuvail	Opthalmic NSAIDS Fax Form
Ophthalmic Prostaglandins	Rescula, Xalatan, Zioptan	Opthalmic Prostaglandins Fax
Opioids (long-acting oral)	Arymo ER, Avinza, Embeda, Exalgo, Hysingla ER, Kadian, MS Contin, Nucynta ER, Opana ER, Oxycodone extended-release tablets, OxyContin, Xtampza ER, Zohydro ER	Opioids (long-acting oral) Fax Form
Otic Antibiotics	Cetraxal	Otic Antibiotics Fax Form
Pancreatic Enzymes	Pancreaze, Pertzye, Ultresa	Pancreatic Enzymes Fax Form
Testosterone (topical)	Fortesta, Striant, Testim, testosterone gel, Vogelxo	Testosterone (topical) Fax Form
Tetracyclines (oral)	Acticlate, Adoxa, Alodox, Avidoxy, Dynacin, Minocin, Monodox, Morgidox, Oracea, Solodyn, Vibramycin, Doxycline IR-DR	Tetracyclines Fax
Topical Corticosteroids	Branded Topical Corticosteriods	Topical Corticosteroids Fax
Topical Rosacea	Finacea, MetroCream, MetroGel, MetroLotion, Noritate Cream, Rosadan, Soolantra	Rosacea Fax
Transdermal Estrogen	Elestrin, Estrasorb, EstroGel	Estrogen Fax

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Coverage Management (Quantity Limits)

Quantity Limits

For certain drugs, Medical Mutual limits the amount of the drug that will be covered per prescription or for a defined period of time. Quantity limits are based on the FDA approved dosing or dosing recommendations supported by evidence based guidelines. For these certain drugs, a coverage review is needed to request additional quantities.

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.

Formulary Exceptions

Some Medical Mutual formularies, including the High Performance Plus and National Preferred formularies, only provide coverage for the listed drugs on their respective formulary. If the member has tried and failed all the listed drugs or is unable to take the listed drugs for medical reasons, you can submit a formulary exception requesting coverage of the non-formulary drug. You can call Express Scripts at (800) 753-2851 to begin the review process for a medication that requires a formulary exception. Our pharmacy benefit manager, Express Scripts, also 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: ExpressPAth Prior Authorization Portal for Providers.

Clinical Services

RationalMed

Helps improve compliance, reduces risk of hospitalization

At Medical Mutual our goal is to help you protect your patient’s health and prevent unnecessary hospitalizations caused by improper use of prescription drugs. Our RationalMed program, which is administered by Express Scripts, integrates medical claims, pharmacy claims, and lab data to build a complete patient profile. RationalMed uses thousands of clinical rules and predictive modeling to identify and alert prescribers on the safe use of medications and to effect changes in prescription drug therapy based on evidence-based guidelines. Examples of what RationalMed looks for include: potential drug interactions; drug reactions based on medical history; drug duplication due to multiple prescribers; duration issues; and gaps in care problems. Provider alert letters are issued to you via fax or electronic medical chart notification when the RationalMed system identifies potential problems related to medical therapies. Medical Mutual and Express Scripts have seen an increase in patient safety with this method compared to standard utilization management programs.

ScreenRx

Helps improve adherence and patient outcomes while lowering healthcare costs

Medication adherence is a problem nationwide. When patients fail to take their medication as prescribed they often suffer from unnecessary complications and also contribute to increased healthcare costs.1,2 Reports estimate that nonadherence costs the U.S. approximately $317 billion annually.2,3 We take adherence very seriously at Medical Mutual and have partnered with Express Scripts to offer our members the ScreenRx program. This program uses advanced analytics to detect the future risk of nonadherence and provides individually tailored interventions to help members stay adherent. Examples of interventions provided free of charge include:

Medication reminder devices such as pill bottle alarms, organizers, and memory aids
Specialist pharmacist consultations
Home delivery with refill and renewal reminders
Low-cost alternatives
Adherence education and tips

If you have a patient that would benefit from any of these interventions please have them contact the toll free Rx Member Service phone number located on their member ID card and ask to speak to a pharmacist regarding a question about taking their medication.

Briesacher BA, Quittner AL, Saiman L, Sacco P, Fouayzi H, Quittell LM. Adherence with tobramycin inhaled solution and health care utilization. BMC Pul Med. 2011;11:5.
Badesch DB, Raskob GE, Elliott CG, et al. Pulmonary arterial hypertension - Baseline characteristics from the REVEAL Registry. Chest. 2010;137(2):376-387.
New England Healthcare Institute (NEHI). Thinking outside the pillbox: a system-wide approach to improving patient medication adherence for chronic disease. Available at: http://www.nehi.net/publications/44/thinking_outside_the_pillbox_a_systemwide_approach_to_improving_patient_medication_adherence_for_chronic_disease.

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.

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