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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.

Formulary Drug Search Tool

2016 Comprehensive Basic/Basic Plus Formulary (Commercial Plans)

2016 Comprehensive Basic/Basic Plus Formulary (Metal Plans)

Monthly Formulary Changes

2016 Step Therapy Changes

2015 Step Therapy Changes

2016 Medicare Part D Formulary

Coverage Management (Prior Authorization)

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.

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
Adempas	Adempas	Adempas Fax Form
Afinitor	Afinitor	Afinitor Fax Form
Alecensa	Alecensa	Alecensa Fax Form
Ampyra	Ampyra	Ampyra Fax Form
Androgens-Anabolic Steriods	Androl-50, Danazol, Nandrolone, Oxandrin
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)
Anti-Influenza Therapy	Relenza, Tamiflu	Anti-Influenza Therapy Fax Form
Antiemetic Agents	Aloxi, Anzemet, Granisol, Kytril, Sancuso, Zofran	Antiemetic Agents Fax Form
Antipsoriatic Agents	Enbrel, Stelara, Taltz	Enbrel Fax Form, Stelara Fax Form, Taltz Fax Form
Apokyn	Apokyn	Apokyn Fax Form
Asthma	Xolair	Xolair Fax Form
Atopic Dermatitis	Elidel, Protopic	Atopic Dermatitis Fax Form
Atopic Dermatitis PST	Elidel, Protopic	Atopic Dermatitis Fax Form
Aubagio	Aubagio	Aubagio 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
Cometriq and Cabometyx	Cabometyx, Cometriq	Cometriq and Cabometyx Fax form
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
Dacogen	Dacogen/Vidaza	Dacogen Fax Form
Daliresp	Daliresp	Daliresp Fax Form
Emend	Emend	Emend Fax Form
Entresto	Entresto	Entresto Fax Form
Entyvio	Entyvio	Entyvio Fax Form
Erivedge	Erivedge
Erythroid Stimulants	Aranesp, EPO, Epogen, Mircera, Procrit	Erythroid Stimulants Fax Form, Mircera Fax Form
Esbriet	Esbriet
Farydak	Farydak	Farydak Fax Form
Gaucher Disease Agents	Cerdelga, Cerezyme, Elelyso, Vpriv, Zavesca	Gaucher Fax Form
Gilenya	Gilenya	Gilenya Fax Form
Gilotrif	Gilotrif
Gleevec	Gleevec	Gleevec Fax Form
Global Prior Authorization	Xiidra, Zurampic	Global Prior Authorization Fax Form
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, Firazyr, Kalbitor, Ruconest	Berinert Fax Form, Cinryze Fax Form, Firazyr Fax Form, Kalbitor Fax Form, Ruconest Fax Form
Hepatitis C Drugs	Daklinza, Epclusa, Harvoni, Olysio, Sovaldi, Technivie, Viekira, Zepatier	Daklinza, Harvoni, Olysio Fax Form, Sovaldi Fax Form, Technivie Fax, Viekira, Zepatier Fax Form
Hetlioz	Hetlioz	Hetlioz Fax Form
Ibrance	Ibrance	Ibrance Fax Form
Iclusig	Iclusig	Iclusig Fax Form
Imbruvica	Imbruvica	Imbruvica Fax Form
Immune Globulins (IV)	Immune Globulins (IV)
Immune Globulins (SC)	Immune Globulins (S)
Inlyta	Inlyta
Iressa	Iressa	Iressa Fax Form
Jakafi	Jakafi	Jakafi Fax Form
Juxtapid	Juxtapid	Juxtapid Fax Form
Kalydeco	Kalydeco	Kalydeco Fax Form
Korlym	Korlym	Korlym Fax Form
Lemtrada	Lemtrada	Lemtrada Fax Form
Lenvima	Lenvima	Lenvima Fax Form
Leuprolide LA	Lupron Depot, Lupron Depot-Ped, Lupaneta, Eligard	Eligard Fax Form, Lupron Fax Form
Lidoderm		Lidoderm Fax Form
Lonsurf	Lonsurf
Lynparza	Lynparza	Lynparza Fax Form
Mekinist	Mekinist
Movantik	Movantik
Multiple Sclerosis Agents	Avonex, Betaseron, Copaxone, Extavia, Rebif, Zinbryta	Avonex Fax Form, Betaseron Fax Form, Copaxone Fax Form, Extavia Fax Form, Rebif Fax Form
Myalept	Myalept
Myeloid Stimulants	Leukine, Neulasta, Neupogen
Natpara	Natpara	Natpara Fax Form
Nexavar	Nexavar	Nexavar Fax Form
Ninlaro	Ninlaro	Ninlaro
Northera	Northera	Northera Fax Form
Nplate	Nplate	Nplate Fax Form
Nucala	Nucala	Nucala
Nuedexta	Nuedexta	Nuedexta Fax Form
Nuplazid		Nuplazid Fax Form
Ocaliva		Ocaliva Fax Form
Odomzo	Odomzo	Odomzo Fax Form
Ofev	Ofev
Okrambi	Okrambi	Okrambi Fax Forms
Opsumit	Opsumit	Opsumit Fax Form
Orencia	Orencia
Orenitram	Orenitram
Osphena	Osphena	Osphena Fax Form
Otic Antibiotics	Cetraxal	Otic Antibiotics Fax Form
Pegylated Interferons	PegIntron	Pegylated Interferons Fax Form
Plegridy	Plegridy	Plegridy Fax Form
Pomalyst	Pomalyst
Praluent	Praluent
Promacta	Promacta	Promacta 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
Repatha	Repatha
Restasis		Restasis Fax Form
Revlimid	Revlimid	Revlimid Fax Form
Rheumatological Agents	Actemra IV, Actemra SC, Arava, Cimzia, Humira, Kineret, Otezla, Remicade, Rituxan, Simponi, Xeljanz and Xeljanz XR	Actemra IV Fax Form, Actemra SC Fax Form, Arava Fax Form, Cimzia Fax Form, Humira Fax Form, Kineret Fax Form, Otezla Fax Form, Remicade Fax Form, Rituxan Fax Form, Simponi Fax Form, Xeljanz Fax Form
Sprycel	Sprycel	Sprycel Fax Form
Stivarga	Stivarga
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
Tafinlar	Tafinlar
Tarceva	Tarceva	Tarceva Fax Form
Tasigna	Tasigna	Tasigna Fax Form
Tazarotene Cream	Tazorac	Tazorac Fax Form
Tecentriq		Tecentriq Fax Form
Tecfidera	Tecfidera	Tecfidera Fax Form
Technivie	Technivie	Technivie 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
Tysabri	Tysabri	Tysabri Fax Form
Uptravi	Uptravi	Uptravi
Venclexta		Venclexta Fax Form
Victrelis	Victrelis	Victrelis Fax Form
Vidaza	Vidaza/Dacogen	Vidaza Fax Form
Votrient	Votrient	Votrient Fax Form
Xalkori	Xalkori
Xeloda	Xeloda
Xtandi
Xuriden and Vistogard	Xurident	Xuriden and Vistogard Fax Form
Xyrem	Xyrem	Xyrem Fax Form
Zaltrap		Zaltrap Fax Form
Zarxio	Zarxio	Zarxio Fax Form
Zelboraf	Zelboraf
Zydelig	Zydelig	Zydelig Fax Form
Zykadia	Zykadia	Zykadia Fax Form
Zytiga	Zytiga

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Coverage Management (Step Therapy)

Coverage Management

Overview of Coverage Management Programs

Coverage Management Updates

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 Cleansers	Branded Prescription Acne Cleansers
Acne - Topical Kits	Branded Prescription Acne Kits
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
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
Beta-Blocker	Branded Beta-blockers and Beta-blocker Combinations
Beta2 Agonists (short-acting) Inhalers PST	Maxair Autohaler, 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
Diabetes - SGLT-2	Farxiga, Invokana, Invokamet, Jardiance, Xigduo XR, Synjardy
Diabetes - SGLT-2/DPP-4	Glyxambi
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	Auvi-Q	Epinephrine auto-injectors Fax Form
Erectile Dysfunction	Levitra, Staxyn, Stendra	Erectile Dysfunction Fax Form
Erythroid Stimulants PSM	Aranesp, Epogen	Erythroid Stimulants Fax Form
Follitropins	Bravelle, Follistim AQ	Follitropins Fax Form
Gabapentin	Gralise, Horizant, Lyrica, Neurontin
Glaucoma Ophthalmic Alpha Adrenergic Agonist	Alphagan P 0.15%, Iopidine 0.5% and 1%
Glaucoma Ophthalmic Beta-Adrenergic Blocker	Istalol, Betagan, Timoptic, Timoptic XE
Glaucoma Ophthalmic Carbonic Anhydrase Inhibitor	Trusopt
Glaucoma Ophthalmic Combination Product	Cosopt
Glucagon-Like Peptide-1 (GLP-1) Agonists	Tanzeum, Trulicity, Victoza	GLP-1 Agonists Fax Form
Gonadotropin Releasing Hormone (GnRH) Antagonists	Cetrotide	GnRH Antagonists Fax Form
HMG-CoA Reductase Inhibitors	Altoprev, Caduet, Crestor, Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Zocor
Hypnotics		Hypnotics Fax Form
Inflammatory Bowel	Asacol, Asacol HD, Delzicol, Dipentum
Inhaled Corticosteroids		Inhaled Corticosteroids Fax Form
Insulin (other)	Novolin 70/30, Novolin N, Novolin R	Insulin (other) Fax Form
Insulin (rapid-acting)	Apidra, Apidra Solostar, Novolog, Novolog Mix 70/30	Insulin (rapid-acting) Fax Form
Intranasal Steroids	Beconase AQ, Dymista, Nasacort AQ, Nasonex, Omnaris, Qnasi, Rhinocort Aqua, Veramyst, Zetonna	Intranasal Fax Form
Metformin ER	Fortamet, Glucophage XR, Glumetza, Metformin ER	Metformin Fax Form
Methotrexate Injection PST	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
Nonsteroidal Anti-inflammatory Drug (NSAID)	Branded NSAIDs and topical diclofenac gel
Oncology Care Value Program	Nexavar, Afinitor, Avinitor Disperz, Lenvima, Xtandi
Ophthalmic NSAIDS	Acular, Acular LS, Acuvail
Ophthalmic Prostaglandins	Rescula, Xalatan, Zioptan	Ophthalmic Prostaglandins Fax Form
Opioids (long-acting oral)	Avinza, Embeda, Exalgo, Kadian, MSContin, Oramorph SR, Oxycodone extended-release tablets	Opioids (long-acting oral) 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
Topical Corticosteroids	Branded Topical Corticosteriods
Topical Rosacea	Finacea, MetroCream, MetroGel, MetroLotion, Noritate Cream, Rosadan, Soolantra
Transdermal Estrogen	Elestrin, Estrasorb, EstroGel

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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.

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.

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