Medical Mutual - Individual Health Insurance, Group

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.

Rx Benefits Overview

Expand
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:

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
Antidepressants Therapy

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. 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
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
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
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
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.

Desktop Browsers	Browser Version
Internet Explorer	v.11
Internet Explorer	v.10
Internet Explorer	v.9
Internet Explorer	v.8
Firefox	Latest Version and 2 Previous
Chrome	Latest Version and 2 Previous
Safari	7.x.x
Safari	6.x.x
Safari	5.x.x