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.

2019 Formularies

2019 Comprehensive Basic Plus formulary (Medical Mutual commercial plans)

2019 Comprehensive Basic Plus formulary (MHS plans)

2019 Comprehensive High Performance Plus formulary (ACA metal plans)

2019 Comprehensive National Preferred Plus formulary (select self-funded plans)

2019 National Preferred Plus Formulary, Preferred Drug List Exclusions

Updates to the National Preferred/National Preferred Plus Formulary Effective July 1, 2019

Updates to Step Therapy Effective July 1, 2019

Monthly Formulary Changes

Please visit the U.S. Food & Drug Administration’s website to learn about current drug recalls and shortages.
Drug recalls: https://www.fda.gov/Drugs/DrugSafety/DrugRecalls/default.htm
Drug shortages: https://www.accessdata.fda.gov/scripts/drugshortages/default.cfm#A

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

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

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

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.

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.

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.

1. 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.
2. Badesch DB, Raskob GE, Elliott CG, et al. Pulmonary arterial hypertension - Baseline characteristics from the REVEAL Registry. Chest. 2010;137(2):376-387.
3. 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.

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.

• 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.