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Pharmacy Services |
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Pharmaceutical services provide First Choice members with needed pharmaceuticals as ordered through valid prescriptions from licensed prescribers for the purpose of saving lives in emergency situations or during short term illness, sustaining life in chronic or long-term illness or limiting the need for hospitalization. Members have access to most national chains and many independent pharmacies.
Monthly Prescription Limits First Choice members who are younger than 21 years of age are eligible for unlimited prescriptions or refills. First Choice members who are 21 years of age and older are limited to four prescriptions or refills per month with certain exceptions. Medications used to treat the following conditions are exempt from the four prescriptions limit:
A maximum of seven prescriptions will be covered per month. To request a prescription limit override for any other condition, the prescriber should contact Select Health/AmeriHealth Mercy Pharmacy Services at 1.866.610.2773 or fax to 1.866.610.2775. Coverage of Generic Products Select Health does not cover brand name products for which there are “A” rated, therapeutically equivalent, less costly generics available unless prior authorization is secured. Prescribers who wish to prescribe brand name products must furnish documentation of generic treatment failure prior to dispensing. The treatment failure must be directly attributed to the patient’s use of a generic of the brand name product. Exceptions to the generic requirement include brand name products of: digoxin, warfarin, theophylline (controlled release), levothyroxine, pancrelipase, phenytoin, carbamazepine and continued treatment utilizing clozapine. Over-the-Counter Drugs All members are covered for certain over-the-counter (OTC) drugs with a prescription written by a doctor. For adult members, these prescriptions will apply toward the monthly limit. Products will be dispensed generically when available as outlined above. Co-payments Members 19 years of age and older are subject to a $3.40 co-payment per prescription. The following members are exempt from a co-payment:
Prior Authorization In a continuing effort to improve patient care and pharmaceutical utilization, Select Health, in conjunction with its PBM, Perform Rx, has implemented a prior authorization (PA) program for the initial prescription of certain medications. Requests for PA medications should be directed to Select Health/AmeriHealth Mercy Pharmacy Services at 1.866.610.2773 or faxed to 1.866.610.2775. In most cases where the prescribing practitioner has not obtained prior authorization, members will receive a five-day supply of the medicine until authorization can be obtained. All requests must be completed within five days from the initial request. Download the prior authorization request form. Preferred Drug List Select Health maintains a Preferred Drug List (PDL). The PDL represents therapeutic recommendations based on documented clinical efficacy, safety and cost-effectiveness. All non-preferred medications will require prior authorization. Select Health’s criteria require a trial and failure or intolerance of one to three preferred medications, depending on the class. Requests for prior authorization medications should be directed to Select Health/AmeriHealth Mercy Pharmacy Services at 1.866.610.2773 or faxed to 1.866.610.2775. Download a copy of our PDL. Providers may request the addition of a medication to the list. Requests must include the drug name, rationale for inclusion on the list, role in therapy and medications that may be replaced by the addition. Please direct such requests to the Pharmacy and Therapeutics Committee at Select Health, PO Box 40849, Charleston, SC 29423. Appeal of Prior Authorization Denials Prior authorization denials may be appealed. Please see the section of the provider manual entitled “Medical Review Determination” to review the appeal process. |
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