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Ambetter’s Pharmacy Program

Pharmacy Program

Ambetter from Superior HealthPlan is committed to providing appropriate, high quality, and cost effective drug therapy to all Ambetter from Superior HealthPlan members. Ambetter from Superior HealthPlan works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Ambetter from Superior HealthPlan covers prescription medications and certain over-the-counter (OTC) medications when ordered by a practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.

Preferred Drug List

The Ambetter from Superior HealthPlan Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at network pharmacies. The Ambetter from Superior HealthPlan PDL is continually evaluated by the Ambetter Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of Medical Directors, Pharmacy Directors, and physicians, pharmacists, and other healthcare professionals.

Pharmacy Benefit Manager

Ambetter from Superior HealthPlan works with Envolve Pharmacy Solutions to process pharmacy claims for prescribed drugs. Some drugs on the Ambetter from Superior HealthPlan PDL may require prior authorization (PA), US Script is responsible for administering this process. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager.

Specialty Drugs

Certain medications are only covered when supplied by Ambetter from Superior HealthPlan specialty pharmacy provider. Tier 4 drugs on the Preferred Drug List represent Specialty Drugs.

AcariaHealth is the preferred specialty pharmacy provider of Ambetter from Superior HealthPlan. All specialty drugs, such as biopharmaceuticals and injectables, require PA to be approved for payment by Ambetter from Superior HealthPlan.

AcariaHealth provides the following services:

  • A dedicated, multilingual team available 24 hours a day, 7 days a week to meet the unique needs of each patient
  • Disease-specific product education and training Customized treatment programs and compliance monitoring
  • Prior authorization support
  • Timely delivery to your office or the patient’s home, as requested

Drug or disease state specific enrollment forms can be found on the Ambetter from Superior HealthPlan website.

Dispensing Limits

Drugs may be dispensed up to a maximum of thirty-one (31) days supply for each new prescription or refill. A total of 80% of the days supply or 25 days must have elapsed before the prescription can be refilled for non-controlled-substance PDL drugs. A total of 90% of the days supply must have elapsed before the prescription can be refilled for controlled substances and narcotic PDL drugs.

Appropriate Use and Safety Edits

The health and safety the member is a priority for Ambetter from Superior HealthPlan. One of the ways we address member safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

Prior Authorizations

Some medications listed on the Ambetter from Superior HealthPlan PDL may require PA. The information should be submitted by the practitioner or pharmacist to US Script on the Medication Prior Authorization Form. This form should be faxed to US Script at 1-866-399-0929. This document can be found on the Ambetter from Superior HealthPlan website.

Ambetter from Superior HealthPlan will cover the medication if it is determined that:

  1. There is a medical reason the member needs the specific medication.
  2. Depending on the medication, other medications on the PDL have not worked.

Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the Ambetter from Superior HealthPlan P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Ambetter from Superior HealthPlan will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Step Therapy

Some medications listed on the Ambetter from Superior HealthPlan PDL may require specific medications to be used before the member can receive the step therapy medication. If Ambetter from Superior HealthPlan has a record that the required medication was tried first the step therapy medications are automatically covered. If Ambetter from Superior HealthPlan does not have a record that the required medication was tried, the member’s practitioner may be required to provide additional information. If authorization is not granted, Ambetter from Superior HealthPlan will notify the member and their practitioner and provide information regarding the appeal process.

Quantity Limits

Ambetter from Superior HealthPlan may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a PA may be requested. If Ambetter from Superior HealthPlan does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Age Limits

Some medications on the Ambetter from Superior HealthPlan PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care.

Gender Limits

Some medications on the Ambetter from Superior HealthPlan PDL may be limited to one gender. These limits are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Gender limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Formulary Exception Requests

If the member requires a medication that does not appear on the PDL, the member’s practitioner can make a medical formulary exception request for the medication. It is anticipated that such exceptions will be rare as the PDL medications are appropriate to treat the vast majority of medical conditions.

For a formulary exception request Ambetter from Superior HealthPlan requires:

  • Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or
  • Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or
  • Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication.

These requests are reviewed by a licensed clinical pharmacist using the criteria established by the Ambetter P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Ambetter from Superior HealthPlan will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Newly Approved Products

Ambetter from Superior HealthPlan reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If Ambetter from Superior HealthPlan does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Over-the-Counter Medications

Ambetter from Superior HealthPlan covers a variety of OTC medications. These medications can be found throughout the Ambetter from Superior HealthPlan PDL. Ambetter from Superior HealthPlan covers OTC products listed in the PDL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

Generic Drugs

When generic drugs are available, the brand name drug will not be covered without Ambetter from Superior HealthPlan authorization. Generic drugs have the same active ingredient and work the same as brand name drugs. If the member or their practitioner feels a brand name drug is medically necessary, the practitioner request the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If Ambetter from Superior HealthPlan does not grant authorization, we will notify the member and their practitioner and provide information regarding the appeal process.

Filling a Prescription

A member can have prescriptions filled at an Ambetter from Superior HealthPlan network pharmacy. If the member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting Ambetter from Superior HealthPlan Member Services. At the pharmacy the member will need to provide the pharmacist with the prescription and their Ambetter from Superior HealthPlan ID card.

Copayments

The amount of copayment for the drugs varies depending upon the benefit plan you have chosen and the tier of the prescription drug. The table below provides a guide to how the drugs are tiered. For exact copayment information, refer to your Explanation of Benefits and Schedule of Benefits. Copayments are collected by the pharmacy at the time the drug is dispensed.

Tier Level Service Description Description
Tier 0 Preventative No copayment for those drugs that are used for prevention and are mandated by Affordable Care Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smoking cessation products may be covered under this tier. Certain age or gender limits apply.
Tier 1 Generic Drug Drugs that offer the greatest value compared to other drugs used to treat similar conditions. Select generic or brand name drugs may be covered under this tier.
Tier 2 Preferred Brand Drug Preferred drugs compared to other drugs, sometimes more expensive, to treat the same conditions.
Tier 3 Non-preferred Brand Drug Higher cost brand name drugs. This tier may also cover those brand name drugs that have a generic alternative.
Tier 4 Specialty Drug Drugs used to treat complex, chronic conditions that may require special handling, storage or clinical management. For members who do not have a 4 Tier plan, these drugs may be found under Tier 3.