At nirvanaHealth, we are committed to providing high quality service to our members. For your convenience, we have provided information to help you navigate your prescription benefits. Explanations of some common prescription drug terms and concepts are included below.
DRUG FORMULARY
What is a drug formulary?
A drug formulary is a list of prescription drugs, both generic and brand name, used by doctors and other health care providers to identify and prescribe drugs that offer the greatest overall value to you. A committee of independent, actively practicing doctors, pharmacists, and other providers regularly review and modify the formulary to maintain its effectiveness and value.
Using drugs on the formulary can help you reduce your out-of-pocket costs. This formulary may help guide you and your doctor in selecting an appropriate drug for you. We encourage you to talk to your them about prescribing formulary drugs and discuss any questions or concerns you have about the drugs you are taking. Remember, only you and your doctor can determine which drug is right for you.
All benefits are subject to plan provisions. Please refer to details about your pharmacy benefit plan and applicable deductibles, copays, and/or co-insurance in your summary of benefits and coverage (SBC). Your up-to-date SBC may be mailed to you at the beginning of your plan benefit year or may be found in your Member Portal. Alternatively, you may contact our Consumer Services team by calling the number on the back of your Member ID Card.
Where can I find the drug formulary?
The National Drug Formulary listed here may not be the drug formulary that applies to your pharmacy benefit plan. You may access your drug formulary on your Member Portal, or, if you would like a printed copy of the drug formulary, please contact our Consumer Services team by calling the number on the back of your Member ID Card.
Additionally, recent drug approvals and drug updates which may affect our national drug formulary can be found here.
What is a drug tier?
Drugs included on the drug formulary are grouped into tiers. A drug’s copay or co-insurance is determined by its tier. There are many reasons why a drug may be placed on a certain tier. A drug that is new may be placed on a higher tier if it has not yet been proven to be safer and more effective than drugs already included on the drug formulary. A drug may also be placed on a higher tier when a lower tier drug can provide similar benefits at a lower cost.
The tiers of a drug formulary may vary based on your plan. A pharmacy benefit may have multiple tiers. An example of the tiers of a drug formulary are provided below:
|
Tier |
Cost |
Drugs Typically Found in This Tier |
|
1 |
Lowest Cost |
Preferred generic drugs |
|
2 |
|
Non-preferred generic drugs |
|
3 |
|
Preferred brand drugs |
|
4 |
|
Non-preferred brand drugs |
|
5 |
|
Preferred specialty drugs, including biosimilars |
|
6 |
Highest Cost |
Non-preferred specialty drugs, including biosimilars |
Some drug formularies may also include preventative drugs that are provided at no cost to you. This will vary based on your plan.
GENERIC DRUGS
What is a generic drug?
The difference between a brand drug and a generic drug is that the generic often costs much less. Once a generic drug becomes available, the brand drug may become non-formulary or excluded from coverage. If you or your doctor requests a brand rather than a generic drug, you may be responsible for the difference in cost between the brand and generic drug plus the higher tier copay or co-insurance. Only your doctor can determine whether a generic alternative is right for you.
Using generic drugs, when right for you, can help you save on your out-of-pocket costs. Like brand drugs, generic drugs are approved by the FDA and meet the same standards. According to the FDA, an FDA-approved generic drug must:
- have the same active ingredients as the brand drug;
- be as safe and effective as the brand drug; and
- meet the same standards set by the FDA.
PRIOR AUTHORIZATION
What is prior authorization?
Your pharmacy benefit plan may require review of medical necessity before covering certain drugs. Prior authorization, also known as preauthorization, is a process that monitors the use of certain drugs to ensure they are prescribed for appropriate clinical situations. Drugs subject to prior authorization typically have safety considerations, high costs, or high potential for inappropriate use. Drugs requiring prior authorization must meet specific medical criteria before your plan will cover them.
How does it work?
The prior authorization process usually involves these steps:
- To initiate a prior authorization, your doctor, pharmacist, or other provider can submit a request electronically through CoverMyMeds, fax a completed prior authorization form to us, or call the number on the back of your Member ID Card.
- Your doctor submits certain medical information to help us make the coverage decision.
- You and your doctor’s office are notified about whether the drug has been approved or not.
If a prior authorization is denied or has not been submitted, the drug will not be covered, and you will be responsible for the entire cost of the drug.
STEP THERAPY
What is step therapy?
Your pharmacy benefit plan may include a step therapy program. Step therapy requires that you must first try certain proven, effective, and lower cost drugs before your plan covers alternative drugs that are more expensive or pose other potential downside such as negative side effects. For example, many brand drugs have less expensive generic or brand alternatives that might be an option for you.
How does it work?
The following is an example of step therapy: You take a generic drug to lower your blood pressure, but it is not working. Your doctor prescribes another drug, but it is still not working. Your doctor prescribes a different drug that is more expensive and requires step therapy. Before the more expensive drug is covered, we will check to see if you have first tried the lower cost drug options included on the drug formulary.
In some cases, your doctor may decide that it is medically necessary to take the “higher step” drug without first trying the “lower step” drugs. If this occurs, the doctor may submit a prior authorization requesting a step therapy exception.
QUANTITY LIMITS
What are quantity limits?
Your pharmacy benefit plan may include a quantity limit program. Quantity limits are designed to help encourage safe and appropriate drug use as intended by the FDA. Overuse of certain drugs may lead to poor outcomes or side effects. Quantity limits may restrict the quantity of a drug per prescription or in a given time period.
How do they work?
If your doctor prescribes a quantity that is greater than what is allowed, they will need to submit a prior authorization requesting a quantity limit exception in order for the drug to be considered for coverage. Without a prior authorization, your prescription may be rejected, or you may be responsible for the cost of the prescription beyond what your coverage allows.
FORMULARY EXCEPTIONS
The drug formulary does not contain a complete list of all available drugs. Some drugs are non-formulary or excluded from coverage. We have a formulary exception process for individuals to request coverage of a drug that is not on our drug formulary. If you would like to initiate a formulary exception, your doctor can submit a prior authorization or contact our Consumer Services team by calling the number on the back of your Member ID Card.
DRUG SAFETY
We are committed to the safety and health of our members. As a service to our members, clients, pharmacies, and prescribers, we monitor drug recalls, withdrawals, and safety alerts communicated by the FDA, drug companies, drug distributors, and regulatory agencies. We monitor these alerts closely to ensure that the drugs dispensed are safe for our members. We will notify members and prescribers affected by these alerts.
For more information about drug safety, please visit our drug recalls, withdrawals, and safety alerts web page here.
APPEALS
What is an appeal?
An unfavorable decision may occur after the review of a prior authorization, step therapy exception, formulary exception, coverage exception, or quantity limit exception. If you disagree with the decision that is made, you or your authorized representative can appeal this decision. Some states may allow your doctor to file an appeal on your behalf in certain circumstances. An appeal is a request to reconsider an unfavorable decision made regarding a product or service (i.e. denial of coverage of a prescription drug). You, your doctor, or your authorized representative may ask for an urgent or standard appeal.
What if my situation is urgent?
If your situation meets the legal definition of urgent, your review will be expedited. Generally, an urgent situation is one in which your health may be in serious jeopardy or, in the opinion of your doctor, you may experience pain that cannot be adequately controlled while waiting for your appeal decision. Call the number on the back of your Member ID Card for any urgent requests.
What if I need help understanding this appeals process?
Additional information regarding your appeals rights is included with the decision letter. If you need assistance understanding your appeals rights, please contact nirvanaHealth by calling the phone number on the back of your Member ID Card.
For your convenience, an appeal request form is available here.
Please send your appeal to the following address:
nirvanaHealth
Attn: Clinical Appeals
136 Turnpike Road,
Southborough, MA 01772
Fax: 508-452-0096 (for standard appeals requests)
508-452-6421 (for urgent appeals requests)
Please include your name, address, Member ID, reasons for appeal, and any supporting documentation you wish to attach. You may send in medical records, doctors’ letters, or any other information relevant to your appeal. Ask your doctor to provide you with any relevant documentation. For formulary exception requests, your doctor must provide a statement supporting coverage of this prescription drug.
External Review:
If you have used all of your internal appeals rights, you may have the right to request an external review by an independent health care professional who has no association with nirvanaHealth. To exercise your right to an external review, you or your authorized representative must submit the external review request. If you have an urgent situation where your health may be in serious jeopardy or, in the opinion of your doctor, you may experience pain that cannot be adequately controlled while waiting for your review decision, you may be entitled to request an expedited external review of our denial.
AUTHORIZED REPRESENTATIVE
An authorized representative is an individual that, with your consent, you may choose to act on your behalf and to make decisions about your care. Examples of an authorized representative are a spouse, family member, or a legally appointed individual such as a guardian. As permitted by regulation, an authorized representative may also be your doctor. Before we can provide or receive information from your authorized representative, you must complete the representative appointment authorization form.
SUBMITTING A PRESCRIPTION DRUG CLAIM (DMR) FORM
Present your Member ID Card at the pharmacy to avoid having to submit a prescription drug claim (DMR) form for reimbursement. If necessary, a prescription drug claim (DMR) form is available for use for prescription claims that were purchased without using your Member ID Card, or due to an emergency situation. You will be reimbursed directly for all covered products as per your prescription drug plan design.
FINANCIAL INCENTIVES
nirvanaHealth does not provide reimbursements, bonuses, or incentives of any kind to staff or health care providers based on consumer utilization of any health care product or service. nirvanaHealth prohibits the use of financial incentives based directly on consumer utilization of services. nirvanaHealth strives to maintain the highest level of objectivity when making utilization management decisions.
