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Pharmacy Overview - Altius Health Plans 


PREFERRED DRUG LIST
Formulary Suggestions for common non-preferred medications
Injectible Medications Purchased through Pharmacies
Recent Changes to the Preferred Drug List

 

The purpose of the pharmacy program is to provide high quality drug therapies to our members while ensuring positive health outcomes at an affordable cost.

The pharmacy benefit will allow members and their dependents to obtain prescription medications from Altius contracted pharmacies or our Prescription Mail Service. This benefit includes birth control pills, insulin, glucose test strips, lancets and insulin syringes.

FILLING A PRESCRIPTION

A thirty (30) day supply of medications (unless redefined by Altius Health Plans Preferred Prescription Drug List, mail order pharmacy service, State or Federal Law, or manufacturer's package size) prescribed by a Provider can be filled by presenting an Altius Health Plans Membership card to any contracted pharmacy. When obtaining a prescription, a member will pay the prescription drug co-payment listed on the Altius Health Plans Membership card or in their medical benefits brochure.

As a member of Altius Health Plans, you must receive your prescription medication from Altius contracted pharmacies. You can consult your Altius Regional Provider Listing for the names of contracted pharmacies or call Altius Customer Service Department at (801) 323-6200.

If a member requires a prescription medication while outside the Altius Service Area, members may contact Express-Scripts Inc. Customer Service Department toll free at 1-800-698-0149 for the nearest contracted pharmacy. Members may also pay fee for service for a prescription and mail their information along with receipts to Express-Scripts. Inc. for reimbursement. Members may also contact Express-Scripts Inc. Customer Service Department to obtain forms and instructions.

MAKING YOUR PREFERRED DRUG LIST
WORK FOR YOU

using your Altius Preferred Drug List can save you time and money!

  • Take this list with you when you visit your physician - preferred medications are available at lower copays. By getting a prescription for a preferred medication at your physician's office you can avoid delays at the pharmacy.
  • What about generics? Ask your physician or pharmacist if your prescription is available in a therapeutically equivalent generic. Most Altius plans allow for a lower copay for generic medications and your physician or pharmacist will be happy to answer any questions.
  • What if my medication is not on the list? Talk to your physician about a formulary alternative. The Altius’ Preferred Drug List provides sound clinical choices for all disease states, yet, non-preferred brand name medications require the highest copay.
  • How do I keep my monthly prescription costs under control? Good question! First, work with your physician to choose medications that are on the preferred list and choose generics when possible. Second, check out the mail order program. Some maintenance medications are available through the mail order program at only 2, or 3 copays for a 3 month (90 day) supply. Check your benefit brochure for the details of your plan. That’s savings delivered right to your door!



FORMULARY FAQS

I’ve never heard of a formulary before. What is it?

One way to manage your prescription benefit is with a formulary. A formulary, or list of preferred medications, was developed by a committee of pharmacists and physicians to include drugs that are the safest, most effective, and most economical. This committee meets regularly to discuss new drugs and trends in drug therapy. The formulary list may change periodically to reflect their new findings. To ensure the use of the appropriate drugs at the most cost effective prices, you will have the option of using the formulary list of the preferred brand name and generic medications at lower coinsurance amounts. Drugs from the formulary provide a safe, effective, and affordable alternative to non-formulary drugs, which will cost you more.

My pharmacist recommends I use a generic drug instead of the brand my physician prescribed. Is this recommended?

A generic drug is the term used to describe a drug once the original drug manufacturer’s brand name patent has expired. Generic drugs tend to cost less since many of the research, development, and marketing costs have been paid by the original manufacturer. Each generic drug manufacturer must meet the same strict FDA guidelines followed by the original brand name manufacturer. In general, most generic drugs are considered part of the formulary, even though they are not listed. It is important to note that the formulary will not restrict your access to medications. It simply requires that you pay more if you want brand name drugs that are not on the formulary. To save you money, we encourage you to use generic drugs whenever possible. When your doctor is prescribing a new medication, you should ask if a generic drug is available and appropriate for your condition.

So how can I keep my drug costs down?

  • Bring a copy of the formulary with you when you visit the doctor. It will be much more efficient for the doctor to pick a drug from the list than to change the prescription after you try to have it filled.
  • Ask for generic drugs whenever they are available. The FDA has systems in place to assure that the medications are the same strength and quality as the brand name drugs and that they will act the same way in your body.
  • Consider having your maintenance medications filled at the mail order to conserve on the amount of money you pay as co-payment. Alternatively, you could use the Express Scripts internet pharmacy by simply logging on to Express Scripts to order your prescriptions.
  • Use a pharmacy in the network.

What is a Generic Name for a drug? I thought I was getting a brand name drug.

All drugs must have a generic name assigned at the time of FDA approval. This allows pharmacists and doctors better understand the classification of drugs on the market. Think of it in terms of a common OTC drug such as aspirin. There are many brands of aspirin on the market, but they all have the same generic name of acetylsalicylic acid.

QUANTITY LEVELS ON MEDICATIONS


Altius Health Plans has placed quantity levels on select medications. This is to ensure that our members receive the recommended and proper dose and length of therapy for their specific disease state. Also, this program will ensure patients graduate to more cost saving therapies.

Medications with quantity levels will be limited to the FDA and Altius’ Pharmacy and Therapeutics Committee’s recommendations per each refill or month.

PRIOR AUTHORIZATION

Some high-risk medications need prior-authorization from Altius before they can be dispensed. These drugs were chosen due to their high potential for adverse reactions, contraindications, potential for abuse and cost. Medications that require prior authorization are listed below. You or your physician may contact Altius’ Prior Authorization Department at (801) 323-6440 or 1-800-879-0234 for an authorization form to be faxed to your provider or his/her office. Your provider must complete the request and fax it back to the Prior Authorization Department for an authorization review. Approval or denial will be communicated to your provider. You may also phone the Prior Authorization Department for a status of your request.

PRESCRIPTION
MAIL SERVICE

The prescription mail order service program allows a member to receive a 90-day supply of maintenance medication while only paying one, two or three co-payments, depending upon your prescription benefit. Refer to your benefit brochure for the details of your plan.

What does "maintenance medication" mean? A maintenance medication is any prescription that is defined by Altius to be taken on a daily basis. Examples include but are not limited to medications for blood pressure, asthma, antidepressants, oral anticoagulants, diabetes, hormone replacement and birth control.

Non-maintenance medications are not available through mail order and include antihistamines (Allegra, Claritin and Zyrtec), antibiotics, pain management (hydrocodone), muscle relaxants, anti-migraine, medications for sleep or anxiety (alprazalam, Ambien and diazepam), acne preparations and topical creams and ointments. The Preferred Drug list identifies non-maintenance medications with an asterisk (*).

Mail Order is Easy!

  • Obtain from your physician a new prescription for a 90-day supply for each medication or refill (when the prescription has expired).
  • Fill out and mail the Mail Pharmacy Service form, available from Altius customer service at 1-800-377-4161or from Express Script Customer service at 1-800-698-0149.
  • You will receive your medications in about 14 days. Since this can take up to two weeks make sure you have a sufficient quantity on hand (a 2-week supply) so you don’t run out while waiting for your medication to arrive in the mail.
  • You may access the status of your order by contacting Express-Scripts Inc. web site. Go to Member Services and then Mail Service Refills.

What about refills?

  • Three weeks before your medication is gone, simply call the 24-hour refill line, 1-800-698-0149.
  • If you try to refill your prescription too soon, Express Scripts will not recognize the refill order and you will need to request it again when you are within 3 weeks of the refill date. This includes new prescriptions being mailed in or phoned-in requests from your physician.



If you prefer using the internet for your refills, you may visit Express Scripts' Mail Service Pharmacy. And follow their online directions. New prescriptions must be mailed or phoned in by your physician.

Express Scripts



PHARMACY LIMITATIONS

Prescriptions may only be filled for a 30-day supply of medication unless redefined by Altius Health Plans' Preferred Drug List, mail pharmacy service, State or Federal laws or manufacturer's package size.

Hospital discharge prescriptions must be filled at an Altius Health Plans participating pharmacy.

The following medications will be excluded from Altius Health Plan's pharmacy benefit:

  • Experimental medications
  • Over the counter medications
  • Medications for non-approved FDA indications or non-approved indications as determined by Altius Health Plans.
  • Infertility medications.
  • Hypodermic needles
  • Injectible, except insulin, Imitrex, Glugagon, Lovenox and Epi-pen (bee sting kits)
  • Natural progesterone (including suppositories and cream)
  • Smoking cessation products
  • Therapeutic devices or support garments (May be covered as a medical benefit)
  • Skin patches for motion sickness.
  • Medications or nutritional supplements for weight loss or weight gain for non-medical conditions.
  • Immunizations and medications required exclusively for foreign travel
  • RELENZA and Tamiflu
  • Hair growth products
  • Medications for athletic and mental performance
  • Medications for the treatment of nail fungus.
  • Impotence medications, unless specifically included in a specific Altius Health Plans' Pharmacy Benefit.
  • Avita, Renova, Propecia, Zyban, Potaba, Xenical, Meridia, Vaniqua, Sarafem & Aggrenox
  • VITAMINS (except prescription prenatal vitamins)
  • Compounded Powders
  • Picovir
  • Compounded estrogen, testosterone cream & suppositories

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