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.

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 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 and using the following tools.

Basic Formulary

2015 Formulary Overview

2015 Monthly Formulary Changes

Step Therapy Changes Effective 8/3/2015

Specialty Drug List

Affordable Care Act Required Preventative Medications


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 Gel
Adempas
Afinitor
Anadrol-50, Android, Androxy, Delatestryl, Depo-Testosterone, Methitest, Nandrolon, Oxandrin, Straint, Tesamone, Testopel, Testred, Winstrol
Atacand, Atacand HCT, Avalide, Avapro, Cozaar, Diovan, Diovan HCT, Edarbi, Edarbyclor, Exforge, Hyzaar, Micardis, Micardis HCT, Teveten, Teveten HCT
Relenza, Tamiflu
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
Aloxi, Anzemet, Granisol, Kytril, Sancuso, Zofran
Diflucan, Lamisil, Sporanox
Apokyn
Asthma
Elidel, Protopic
Elidel, Protopic
Benlysta
Beta2 Agonist/Corticosteroid Inhalers
Advair Diskus, Advair HFA, Breo Ellipta
Maxair Autohaler, Proventil HFA, Xopenex HFA
Actonel, Atelvia, Binosto, Boniva, Fosamax, Fosamax Plus D
Botox, Botox Cosmetic, Dysport, Myobloc, Xeomin
Breast Cancer - Primary Prevention
Raloxifene, Tamoxifen
Caprelsa
Cialis (2.5 & 5 MG)
Cometriq
Contraceptive Agents
All contraceptive agents not being prescribed for contraceptive purposes
Cosentyx
Dacogen/Vidaza
Daliresp
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)
Jentadueto, Kazano, Nesina, Tradjenta
Emend
Auvi-Q
Levitra, Staxyn, Stendra
Erivedge
Aranesp, EPO, Epogen, Procrit
Aranesp, Epogen
Esbriet
Farydak
Abstral, Actiq, Fentanyl Powder, Fentora, Onsolis
Bravelle, Follistim AQ
Cerezyme, Vpriv, Zavesca
Gilenya
Gilotrif
Gleevec
Tanzeum, Trulicity, Victoza
Cetrotide
Accretropin, Genotropin, Geref, Humatrope, Increlex, Iplex, Miniquick, Nordiflex, Norditropin, Nuspin, Nutropin, Omnitrope, Protropin, Saizen, Serostim, Tev-Tropin, Valtropin, Zorbtive
HAE (Hereditary Angioedema) Agents
Hetlioz
Ambien, Ambien CR, Belsomra, Edluar, Intermezzo, Lunesta, Rozerem, Silenor, Sonata, Zolpimist
Hysingla ER
Ibrance
Iclusig
Imbruvica
Incivek
Inlyta
Novolin 70/30, Novolin N, Novolin R
Apidra, Apidra Solostar, Novolog, Novolog Mix 70/30
Beconase AQ, Dymista, Nasacort AQ, Nasonex, Omnaris, Qnasi, Rhinocort Aqua, Veramyst, Zetonna
Jakafi
Kalydeco
Korlym
Lemtrada
Lenvima
Lynparza
Mekinist
Alsuma, Amerge, Axert, Frova, Imitrex, Imitrex STATdose Pen, Imitrex STATdose System, Maxalt, Maxalt MLT, Migranal, Relpax, Sumavel, Treximet, Zomig, Zomig-ZMT
Multiple Sclerosis Agents
Avonex, Betaseron, Copaxone, Extavia, Rebif
Betaseron
Leukine, Neulasta, Neumega, Neupogen
Nexavar
Northera
Nplate
Nuedexta
Ofev
Rescula, Xalatan, Zioptan
Avinza, Embeda, Exalgo, Kadian, MSContin, Oramorph SR, Oxycodone extended-release tablets
Opsumit
Orenitram
Cetraxal
Pancreaze, Pertzye, Ultresa
PegIntron
Plegridy
Pomalyst
Promacta
Proton Pump Inhibitors
Aciphex, Dexilant, Iansoprazole, Omeprazole-sodium bicarbonate, Prevacid, Prilosec packets, Protonix, Zegerid
Nuvigil, Provigil
Adcirca, Flolan, Letairis, Remodulin, Revatio, Tracleer, Ventavis
Revlimid
Rheumatological Agents
Solodyn
Sprycel
Stivarga
Sublingual Immunotherapy
Sutent
Synagis
Tafinlar
Tarceva
Tasigna
Tazorac
Tecfidera
Tecfidera
Temodar
Fortesta, Striant, Testim, testosterone gel, Vogelxo
Thalomid
Avita, Retin-A
Tykerb
Tysabri
Victrelis
Vidaza/Dacogen
Votrient
Xalkori
Xeloda
Xyrem
Zelboraf
Zohydro ER
Zykadia
Zytiga

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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. 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

Medical Mutual is committed to creating a diverse workforce.

Learn More

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