Pharmacy Center

Introduction

ConnectiCare and Express Scripts are pleased to provide the ConnectiCare Pharmacy Drug List as a reference for drug product selection, in a Tiered format. Drug placement in the ConnectiCare Pharmacy Drug List represents the decisions of the ConnectiCare Pharmacy and Therapeutics (P&T) Committee.

“Tiers” refers to copayment levels of cost sharing by the member. Tier 1 is the lowest copayment amount, Tier 2 is intermediate and Tier 3 is the highest standard member copayment. Practitioners who select clinically appropriate drugs from Tier 1 and Tier 2 will be choosing cost-effective drugs for their patients who have their drug benefits administered through ConnectiCare and Express Scripts.

Preface

The ConnectiCare Pharmacy Drug List is organized by sections. Each section contains groups of drugs titled by drug class. The ConnectiCare Pharmacy Drug List is set up to encourage the use of Tier 1 or Tier 2 drugs where appropriate. Over-the-counter (OTC) products, with the exception of insulin and glucose monitoring products, are not covered.

The drug list is separated by tiers or levels in the following manner:

Tier 1:   Lowest member copayment

Tier 2:   Intermediate member copayment: Some branded drugs or supplies

Tier 3:   Highest member copayment: Some branded drugs or supplies

Note: Most of our members will pay additional cost beyond their copayment if they choose to use brand name drugs rather than generics when a generic equivalent is available.

Pharmacy and Therapeutics (P&T) Committee

The ConnectiCare Pharmacy and Therapeutics Committee evaluates new drugs, therapeutic categories, policies and procedures, and other activities that govern the terms of prescription drug coverage. Some of the material submitted for Committee review has been prepared by Express Scripts and some is prepared independently by the ConnectiCare Pharmacy Department. The Committee is composed of local physicians representing many medical specialties, a local community pharmacist, ConnectiCare Medical Director, the ConnectiCare Pharmacy Director and Manager, and a pharmacy consultant from Express Scripts.

The actions of the ConnectiCare P&T Committee in placing drugs in a tier or changing the tier of an existing drug are communicated in the ConnectiCare member newsletter and on the ConnectiCare web site. Please see the ConnectiCare Drug List for the most up-to-date version of the List. To receive a copy of Drug List additions or deletions, call ConnectiCare at (800) 251-7722.

Product Selection Criteria

The ConnectiCare P&T Committee will consider all FDA approved drugs for inclusion in the Pharmacy Drug List. The evaluation includes a literature review and expert opinion may also be sought. Formal reviews are prepared which typically address the following information:

• Safety
• Efficacy
• Cost
• Comparison studies
• Approved indications
• Adverse effects
• Contraindications
• Pharmacokinetics
• Patient compliance considerations
• Medical outcome and pharmacoeconomic studies

When a new drug is considered for drug list inclusion, the P&T Committee will examine the drug relative to similar drugs currently on the drug list. In addition, entire therapeutic classes of drugs are periodically reviewed in an effort to continually promote the most clinically useful and cost-effective agents in a particular therapeutic class. The class review process may result in drugs changing Tier status, which will result in a change in the member’s copayment for those drugs.

Some drugs evaluated by the P&T Committee receive a 3^rd Tier designation on the list. Since 3^rd Tier drugs will cost members more in higher copayments, physicians are encouraged to prescribe drugs in Tier 1 and Tier 2 when appropriate.
All the material in the ConnectiCare Pharmacy Drug List is provided as a reference for drug therapy selection. The final choice of specific drug selection for an individual patient rests solely with the prescriber.

How to Get Prior Authorization for Drugs that Need It

Some drugs, due to their limited uses, potential for misuse, or high cost require prior authorization (PA) from ConnectiCare to monitor and ensure appropriate use. Before the drugs on the Prior Authorization List can be covered by ConnectiCare, the physician prescribing the drug must ask ConnectiCare to authorize its use. When asking for authorization, the physician must send ConnectiCare the medical rationale for the drug selection. The drug will be approved or denied using criteria established and approved by the Pharmacy & Therapeutics Committee. The physician must write or fax ConnectiCare’s Pharmacy Services Department to request prior authorization:

ConnectiCare, Inc.
Pharmacy Services
175 Scott Swamp Road
PO Box 4050
Farmington, CT. 06034-4050
Fax: (860) 674-2851
E-mail: pharmacy@connecticare.com

The following information is needed when requesting prior authorization:

1. Patient’s name, address, and ConnectiCare ID number
2. Physician’s specialty, name, address, and phone number
3. Drug, strength, dosage form, and directions
4. Indication for use
5. Anticipated length of therapy
6. Frequency of refills needed

If the prescribing does not ask ConnectiCare for prior authorization where it is required, the pharmacy will not be able to process your prescription at the appropriate copayment. Your physician must ask ConnectiCare for prior authorization for you to get coverage of these drugs.

Note: The products included on this list are subject to change. Please contact ConnectiCare for the most current list at (800) 251-7722 or access the Prior Authorization List online.

Generic Substitution

Generic substitution is the process by which a generic equivalent is dispensed at the pharmacy rather than the brand name product prescribed. ConnectiCare utilizes a generic substitution program that promotes generic substitution using a MAC list. The MAC list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most generics, but not branded versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA’s review and approval process.
It is recommended that product substitution not be undertaken for any unrated multisource products known to be not bioequivalent

Note: Most of our members will pay additional cost beyond their copayment if they choose not to use a generic equivalent when one is available.

Quantity Limitations

The drugs on the Quantity Management List have limitations on the quantity that can be covered at one time. These quantity limitations (QL) are used to guard against abuse, drug diversion, and inappropriate medical use. Drug use greater than these limits must be prior authorized by ConnectiCare according to the Prior authorization process above. Note: The products included on this list are subject to change, please contact ConnectiCare at (800) 251-7722 for the most current list

Editor

Your comments and suggestions regarding the ConnectiCare Pharmacy Drug List are encouraged. All responses will be reviewed and considered. Please send your comments to:

ConnectiCare, Inc.
Pharmacy Services
175 Scott Swamp Road
PO Box 4050
Farmington, CT 06034-4050
E-mail: pharmacy@connecticare.com

Notice

The information contained in the ConnectiCare Pharmacy Drug List and its appendices is provided by ConnectiCare and Express Scripts, solely for the convenience of medical providers. ConnectiCare and Express Scripts has made every effort to review content for accuracy as of date of printing. Policy changes and changes to the Prior Authorization, Quantity Limit and Drug Lists are made quarterly, or as needed by ConnectiCare Inc. The ConnectiCare Pharmacy Drug List is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. Neither ConnectiCare nor Express Scripts assumes responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information.