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.

Formulary Drug Search Tool

2016 Comprehensive Basic/Basic Plus Formulary (Commercial Plans)

2016 Comprehensive Basic/Basic Plus Formulary (Metal Plans)

2017 Comprehensive Basic Plus Formulary (Commercial Plans), effective January 1, 2017

2017 Comprehensive High Performance Plus Formulary (Metal Plans), effective January 1, 2017

Monthly Formulary Changes

2016 Step Therapy Changes

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 Gel
Addyi
Adempas
Afinitor
Alecensa
Ampyra
Androl-50, Danazol, Nandrolone, Oxandrin
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)
Relenza, Tamiflu
Antipsoriatic Agents
Apokyn
Elidel, Protopic
Aubagio
Benlysta
Bosulif
Botox, Botox Cosmetic, Dysport, Myobloc, Xeomin
Breast Cancer - Primary Prevention
Raloxifene, Tamoxifen
Caprelsa
Cholbam
Cialis (2.5 & 5 MG)
Cinqair
Leukine, Neulasta, Neupogen
Cabometyx, Cometriq
All contraceptive agents not being prescribed for contraceptive purposes
Corlanor
Cosentyx
Cotellic
Dacogen/Vidaza
Daliresp
Emend
Emend
Entresto
Erivedge
Aranesp, EPO, Epogen, Mircera, Procrit
Esbriet
Exondys 51
Farydak
Cerdelga, Cerezyme, Elelyso, Vpriv, Zavesca
Gilenya
Gilotrif
Gleevec, Imatinib
Yosprala, Zurampic
Accretropin, Genotropin, Geref, Humatrope, Increlex, Iplex, Miniquick, Nordiflex, Norditropin, Nuspin, Nutropin, Omnitrope, Protropin, Saizen, Serostim, Tev-Tropin, Valtropin, Zorbtive
HAE (Hereditary Angioedema) Agents
Hetlioz
Ibrance
Iclusig
Imbruvica
Immune Globulins (IV)
Immune Globulins (S)
Inlyta
Iressa
Jakafi
Juxtapid
Kalydeco
Korlym
Lemtrada
Lenvima
Leuprolide LA
Lidoderm or Lidocaine Patch
Lonsurf
Lynparza
Medical Device
Mekinist
Movantik
Avonex, Betaseron, Copaxone, Extavia, Rebif, Zinbryta
Myalept
Natpara
Nexavar
Ninlaro
Northera
Nplate
Nucala
Nuedexta
Nuplazid
Ocaliva
Odomzo
Ofev
Opsumit
Orencia
Orenitram
Orkambi
Osphena
PegIntron
Plegridy
Pomalyst
Praluent
Promacta
Nuvigil, Provigil
Adcirca, Flolan, Letairis, Remodulin, Revatio, Tracleer, Ventavis
Repatha
Restasis
Revlimid
Rheumatological Agents
Sprycel
Stivarga
Strensiq
Sublingual Immunotherapy
Sutent
Sylatron
Synagis
Tafinlar
Tarceva
Tasigna
Tecentriq
Tecfidera
Technivie
Temodar
Thalomid
Abstral, Actiq, Fentora, Lazanda, Subsys
Avita, Retin-A
Tykerb
Tysabri
Uptravi
Venclexta
Victrelis
Vidaza/Dacogen
Votrient
Xalkori
Xeloda
Xiidra
Xolair
Xtandi
Vistogard, Xuriden
Xyrem
Zaltrap
Zarxio
Zelboraf
Zydelig
Zykadia
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

Branded Topical Prescription Acne Products
Branded Prescription Acne Cleansers
Branded Prescription Acne Kits
Atacand, Atacand HCT, Avalide, Avapro, Cozaar, Diovan, Diovan HCT, Edarbi, Edarbyclor, Exforge, Hyzaar, Micardis, Micardis HCT, Teveten, Teveten HCT
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
Elidel, Protopic
Addderall XR, Aptensio XR, Concerta, Daytrana, Dexedrine Spansules, Dyanavel XR, Focalin XR, Metadate CD, QuiliChew ER and IR, Ritalin LA and SR, Vyvanse
Branded Beta-blockers and Beta-blocker Combinations
Maxair Autohaler, Proventil HFA, Xopenex HFA
Actonel, Atelvia, Binosto, Boniva, Fosamax, Fosamax Plus D
Branded Contraceptives
Farxiga, Invokana, Invokamet, Jardiance, Xigduo XR, Synjardy
Glyxambi
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
Auvi-Q
Levitra, Staxyn, Stendra
Aranesp, Epogen
Bravelle, Follistim AQ
Gralise, Horizant, Lyrica, Neurontin
Alphagan P 0.15%, Iopidine 0.5% and 1%
Istalol, Betagan, Timoptic, Timoptic XE
Trusopt
Cosopt
Tanzeum, Trulicity, Victoza
Cetrotide
Altoprev, Caduet, Crestor, Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Zocor
Asacol, Asacol HD, Delzicol, Dipentum
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
Fortamet, Glucophage XR, Glumetza, Metformin ER
Otrexup, Rasuvo
Alsuma, Amerge, Axert, Frova, Imitrex, Imitrex STATdose Pen, Imitrex STATdose System, Maxalt, Maxalt MLT, Migranal, Relpax, Sumavel, Treximet, Zomig, Zomig-ZMT
Branded NSAIDs and topical diclofenac gel
Oncology Care Value Program
Acular, Acular LS, Acuvail
Rescula, Xalatan, Zioptan
Avinza, Embeda, Exalgo, Kadian, MSContin, Oramorph SR, Oxycodone extended-release tablets
Cetraxal
Pancreaze, Pertzye, Ultresa
Fortesta, Striant, Testim, testosterone gel, Vogelxo
Acticlate, Adoxa, Alodox, Avidoxy, Dynacin, Minocin, Monodox, Morgidox, Oracea, Solodyn, Vibramycin, Doxycline IR-DR
Branded Topical Corticosteriods
Finacea, MetroCream, MetroGel, MetroLotion, Noritate Cream, Rosadan, Soolantra
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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© 2016 Medical Mutual®