Rx Information for Psychiatrists
To help clarify the requirements applied to many of the medications you prescribe, we provide the following list of pharmacy management definitions:
Prior authorization requires that the provider submit a letter of medical necessity or fill out a prior authorization form prior to coverage of the requested medication. The SSRI/SNRI form (see attachment) or letter of medical necessity can be faxed to our pharmacy help desk at 1-800-956-2397. They may also be phoned in by calling 1-800-724-5033.
Step therapy, unlike Prior Authorization, allows the claims system to read paid claims in history. If there are paid claims for the required first line medications then the branded SSRI or SNRI will pay when the pharmacist transmits the claim. If there are no paid claims for the required first line medications then the claim will reject as prior authorization required. The SSRI/SNRI form (see attachment) or letter of medical necessity can be faxed to our pharmacy help desk at 1-800-956-2397. They may also be phoned in by calling 1-800-724-5033.
Quantity limits specify the number of units (tabs, caps, mL’s etc.) that can be obtained per 30 day supply. These limits are generally imposed based on the maximum recommended dose of specific medications. They also help to insure that 1 higher strength tablet is used as opposed to 2 lower strength tablets (1 Lexapro 20mg tablet versus 2 Lexapro 10mg tablets). An exception form can be submitted for those unique situations where the quantity limit needs to be overridden.
Tier contingency allows a non-preferred tier 3 drug to pay at a preferred tier 2 copay if certain criteria are met. Tier contingency is either based on provider specialty or previous therapies tried. For instance, Lamictal will pay at tier 2 if written by a psychiatrist or neurologist but will pay at tier 3 for all other providers. Drugs with tier contingency on them do not deny, they either pay at tier 2 or tier 3.
Route of Administration (ROA)
Medications that are not generally self-administered are not covered under the pharmacy benefit. These medications are generally administered by a healthcare provider and should be paid for under the patient’s medical benefit. These medications can be ordered and shipped to your office through CuraScript Pharmacy or Walgreens Specialty Pharmacy. Both of these pharmacies able to bill the patient’s medical benefit for office administered medications. Curascript can reached by phone at 1-866-413-4137. Walgreens Specialty Pharmacy can be reached at 1-866-435-2170.
As of January 1, 2010, step therapy will be required for the following:
|Drug Class||Step Therapy Required for||Requires trial of|
|Anti-depressants||Aplenzin®, Celexa®, Cymbalta®, Effexor XR®, Emsam®, Lexapro®, Luvox CR®, Paxil®, Paxil CR®, Pexeva®, Prozac®, Prozac Weekly®, Sarafem®, Wellbutrin®, Wellbutrin SR®, Wellbutrin XL®, Zoloft®||One of the following if written by a psychiatrist or two of the following if written by any other specialty:
mirtazapine, citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine, bupropion, bupropion SR, bupropion XL
- Pristiq® (desvenlafaxine) requires prior authorization before coverage. Criteria requires a trial of one generic antidepressant and severe intolerance to Effexor XR or Venlafaxine ER if written by a psychiatrist. Criteria requires a trial of two generic antidepressants and severe intolerance to Effexor XR or Venlafaxine ER if written by any other specialty. To request authorization for Pristiq, please complete an exception form. An exception form is included with this mailing.
- Fluoxetine and citalopram are both currently on our generic trial program. The first time a member fills a prescription for a generic medication included in the program at a participating FLRx network pharmacy, the member's copayment / coinsurance for the first 30-day supply will be waived. Please note that the prescription must be written for 30 days. Please note, a small number of benefits do not include the generic trial program.
- Effexor XR is expected to be available generically on July 1st, 2010.
- Aplenzin became available in March of 2009. It has been added to step therapy and has a quantity limit of 30 tablets per 30 day supply.
- Tier Contingency - Abilify®, Geodon®, Risperdal®, Seroquel®, Seroquel XR® and Zyprexa® are currently Tier 3 for patients with a 3 Tier benefit. New users have had a trial and failure on risperidone can obtain any of the above medications at tier 2. Please note they will pay at the Tier 2 copay level only if your patient has had a trial of generic risperidone in our claims history. An exception form can be submitted for any member who has trialed risperidone with a previous insurance carrier.
- Long acting injectable anti-psychotics such as Risperdal Consta and Haloperidol Decanoate are not covered under the pharmacy benefit. Only those medications that are self-administered are covered. Both Curascript and Walgreens Specialty Pharmacies can bill the patient’s medical benefit and ship the medication directly to your office for administration.
- The only anti-psychotic medication on Prior Authorization is Invega. Please see criteria listed below:
|Antipsychosis||Invega®||Failure or intolerance to one anti-psychotic medication and severe intolerance to Risperdal®.|
- Suboxone is currently covered as a preferred brand medication in tier 2 and is also formulary under our closed formulary benefit. Naltrexone is covered as a tier 1 generic.
- In October of 2009, Subutex became available generically. The generic, buprenorphine, is currently available.
- Vivitrol is not covered under the prescription benefit as it is not self-administered. However, it is covered under our medical benefit.
- Antabuse is currently covered at tier 2, Campral is covered at tier 3 with a quantity limit of 180 tablets per 30 day supply.
- Chantix is covered at tier 3 with a QL of 60 tablets per 30 day supply. In addition, Chantix will only be approved for 24 weeks of treatment per year in accordance with the FDA approved dosing.
- Lamictal and Topamax have both been removed from tier contingency due to the availability of generics.
- Depakote and Depakote ER both became available generically in 2009.
- Concerta, Adderall XR and Strattera are the preferred brand medication that pays at tier 2.
- Daytrana and Vyvanse were removed from Prior Authorization in 2009. They continue to be non-formulary in our 2 tier closed formulary.
- Ritalin LA, Focalin and Focalin XR were removed from step therapy in 2009. They continue to be non-formulary in our 2 tier closed formulary.
- Intuniv became available in September of 2009. It is currently placed in Tier 3 in our open formulary and non-formulary in our 2 Tier closed formulary.
We continue to implement step therapy on the branded hypnotics. The criteria is listed below:
|Hypnotics||Ambien®, Ambien CR®, Edular® Lunesta®, Rozerem®, Sonata®||Require a trial and failure of generic Zolpidem.|
FLRx Pharmacy Help Desk
- To submit prior authorization and exception forms:
Fax: (800) 956-2397
- For inquiries:
Phone: (800) 724-5033
If you would like to order medications to be shipped to your office, please contact the participating pharmacies directly, toll-free:
- Mental Health Prior Authorization RequestOpen a PDF Request for Step Therapy Evaluation Prior Auth FormOpen a PDF
- General Exception Request Form (Self Administered Drugs)Open a PDF General Exception Request Form (Self Administered Drugs)Open a PDF
- Quantity Limits for Antidepressants and Antipsychotic MedicationsOpen a PDF Quantity Limits for Antidepressants and Antipsychotic MedicationsOpen a PDF
- Mental Health Medication CostsOpen a PDF Mental Health Medication CostsOpen a PDF