Medicare - Pharmacy Program |
Utilization Management Program
ConnectiCare has developed prior authorization and step therapy criteria that must be met for certain medications before they can be filled. Some drugs, due to their narrow indication, potential for misuse, or high cost require pre-authorization to ensure appropriate access and use. Before these drugs will be covered, the physician must forward the medical rationale for the drug selection to Pharmacy Services. The drug will be approved or denied for coverage based on criteria established and approved by the Pharmacy and Therapeutics (P&T) Committee. Some drugs within the pre-authorization program require other medications be used prior to approval (step therapy).
View the prior authorization list or request a written copy by contacting Medicare Provider Services at 1-877-224-8230.
Step Therapy
The drugs on this list will require prior authorization if the step therapy is not satisfied. Please click on the link below to view the list of drugs that require step therapy approval.
Step Therapy Criteria
Prior Authorization
The drugs on this list will require a Physician Prior Authorization (PPA). Please click on the link below to view the list of drugs that require prior authorization.
Prior Authorization Criteria
Quantity Limits
Some drugs have limitations on the quantity or days supply that can be filled at one time. These limitations are used to control abuse, drug diversion, and inappropriate medical use. Drug use greater than these limits must be pre-authorized. The drugs
on this list have quantity limits. Please click on the link below to view the drugs with quantity limits.
Quantity Limits Criteria
Non-FDA-Approved Uses
A Non-FDA-Approved Drug Use and/or Dose Request Form must be completed when a drug is requested for a non-FDA approved indication. All requests must be submitted to:
ConnectiCare Pharmacy Services
PO Box 1520
JAF Station
New York, NY 10016-1520
Fax: 1-877-300-9695
The request is evaluated by a Medical Director or pharmacist for approval/denial. Pharmacy Services will notify the requesting clinician of the decision.
Addition to Formulary
An Addition to Formulary Request Form is used when a clinician wants to request the inclusion of a drug to the ConnectiCare Drug Formulary. Such requests must be completed and submitted with pertinent clinical data/literature justifying the addition of the drug to the formulary. The request is reviewed by the appropriate specialty subcommittee(s) for their recommendation and then to the P&T Committee for a final decision. All requests must be submitted to:
ConnectiCare Pharmacy Services
PO Box 1520
JAF Station
New York, NY 10016-1520
Or fax to: 1-877-300-9695
Products are extensively reviewed, employing current product information and peer-reviewed literature. The selection process for drugs to be included in the Drug Formularies takes into account members’ needs, clinical efficacy and safety data, and whether there are any advantages over existing formulary drugs.
Following the introduction of any new drug in the U.S. market, the P&T Committee will typically allow for at least a six-month period of study before any final decision on inclusion of a drug to the formulary is made. During this time period, the P&T Committee carefully observes the use and experience of the newly marketed drug in the general population with regard to its efficacy, safety and drug interactions. After this study period, the drug is fully evaluated and a final recommendation is made.
