Introduction

I.               Non-Prescription Medication Policy
II.            Unapproved Use of Formulary Medication
III.          Prior Authorization Procedure
IV.         Unique Patient Needs Non-Formulary Medication
V.            Newly Marketed Products
VI.         Specific Exclusions
VII.       Policy for Injectable Drugs
VIII.     Dispensing Limits
IX.         Mandatory Generic Substitution
X.            DESI Drug Explanation
XI.         Health Industry Numbers
XII.      Where to Call
XIII.    TLC Phone Numbers for Member Services
XIV.    TLC Contacts for Medical Appeals
XV.      Annotations

This formulary describes the circumstances under which pharmacies participating in a particular medical benefit program will be reimbursed for medications dispensed to patients covered by the program.  This formulary does not:

a)     Require or prohibit the prescribing or dispensing of any medication.
b)     Substitute for the independent professional judgment of the physician or pharmacist or
c)     Relieve the physician or pharmacist of any obligation to the patient or others.

I.  Non-Prescription Medication Policy

The TLC program does not cover most over-the-counter medications (OTC).  The only exceptions to this policy are listed in this booklet.  Furthermore, an OTC medication can be reimbursed only if it is written on a valid prescription form by a licensed prescriber.

II.  Unapproved Use of Formulary Medication

Medication coverage under this program is limited to non-experimental indications as approved by the FDA.  Other indications may also be covered if they are accepted as safe and effective by the balance of current medical opinion and available scientific evidence.  Reimbursement decisions for these other indications will be made by Scrip Pharmacy Solutions in accordance with the procedures outlined in section IV.  Experimental, investigational drugs and drugs used for cosmetic purposes are not eligible for coverage.

III.  Prior Authorization Procedure

Prior authorization procedures are used to promote appropriate utilization of selected high risk and/or high cost medication. The Scrip Pharmacy Solutions/TLC program has established the criteria for this system with input from pharmacist and physician practitioners and in consideration of medical literature.  The Pharmacy and Therapeutics Committee will have final approval responsibility for the list of drugs that are subject to prior authorization. 

In order for a dispensed prior authorization medication to be reimbursed to the pharmacy, the patient's prescribing physician must apply for pre-authorization for a specific patient and drug.  The physician may phone or fax Scrip Pharmacy Solutions to request prior authorization:

Scrip Pharmacy Solutions
Prior Authorization Desk
33 North Road
Wakefield, RI 02879-2164
(800) 762-2299 (phone)
(800) 354-5979 (fax)

Please have patient information, including social security number, complete diagnosis, medication history and current medications readily available. 

These phone lines are dedicated to physicians making requests for prior authorization medication items only. Subscribers cannot be assisted if they call the prior-authorization toll-free number.  All faxed approval requests will be responded to within twenty-four (24) hours during the business week and within seventy-two (72) hours on weekends and holidays.  If the request is approved, information in the on-line pharmacy claims processing system will be changed to allow the specific patient to receive this specific drug.  A prior authorization number will be issued to the prescribing physician and is to be clearly written on the top of the prescription to inform the dispensing pharmacist of the approval.  This number is for identification purposes only and does not need to be submitted for adjudication to occur.  If the request is denied, information about the denial will be provided to the physician. 

Medications requiring prior authorization are listed with a prior approval notation throughout the formulary.  The index also includes a "PA" designation for those products requiring prior authorization.  In addition, all injectables (except insulin, Glucagon Kit, Epi-pen, Ana-Kit, and Depo-Provera) require prior authorization. 

IV.  Unique Patient Needs Non-Formulary Medication

This formulary attempts to provide appropriate and cost effective drug therapy to all participants in the Scrip Pharmacy Solutions/TLC program.  If a patient requires medication that is not covered by the formulary, the physician can make a request for payment for the non-covered item.  It is anticipated that such exceptions will be rare, and that formulary medications will be appropriate to treat the vast majority of medical conditions.  Requests for these exceptions should be made in writing by the physician (on the "request for non-formulary medication form" if possible) and mailed or faxed to:

Scrip Pharmacy Solutions
Medical Necessity Desk
33 North Road
Wakefield, RI 02879-2164
(800) 354-5979

Appropriate documentation must be provided to support the request.  A response will be provided within one- (1) business day of receipt of this information.  Approval of non-formulary items will be based upon criteria developed by the Pharmacy and Therapeutics Committee of Scrip Pharmacy Solutions/TLC.

Physicians are expected to comply with this formulary when prescribing medication for those patients covered by the Scrip Pharmacy Solutions/TLC plan.  If a pharmacist receives a prescription for a non-formulary medication, the pharmacist should attempt to contact the prescribing physician to request a change to a product included in this formulary guide.

The pharmacy will not be reimbursed for non-formulary medications.  In an emergency situation outside Scrip Pharmacy Solutions regular business hours, where the physician cannot be contacted, the pharmacist is authorized to dispense a 72 hour emergency supply of a medication, unless the medication is classified as a DESI, LTE or specifically excluded drug category (see section VI) product.  The pharmacist should contact Scrip Pharmacy Solutions Customer Service line at (800) 213-5640 during regular business hours to arrange for reimbursement for the emergency supply.

V.  Newly Marketed Products

Newly marketed drug products will not normally be placed on the formulary during their first year on the market.  Exceptions to this rule will be made on a case by case basis using the medical necessity procedure.

VI.  Specific Exclusions

The following drug categories are not part of the Scrip Pharmacy Solutions/TLC formulary and are not covered by the 72 hour emergency supply reimbursement policy:

Research drugs
Medical supplies and durable medical equipment (except those listed in formulary)
Injectables (except for in-home use administered by patient)
Cough and cold products (except those listed in formulary)
Biologicals
Blood and blood plasma
DESI drugs (see section XI)
Nutritional and dietary supplements
Most vitamins
Antiobesity products
Topical minoxidil
Anti-acne products
Diagnostic products (except those listed in formulary)
Cosmetic drugs
Norplant
Smoking Cessation products
Fertility Drugs
Fluoride Rinses
OTC Medications (see section I)
Sexual Dysfunction products

VII.  Policy for Injectable Drugs

Injections that are self-administered by the patient and/or a family member and are listed within the program formulary are covered on the Scrip Pharmacy Solutions/TLC program.  Scrip Pharmacy Solutions does not cover injections given in the doctors' office or home health.  Any questions regarding this policy should be directed to TLC at the following number:(800) 473-6523

VIII.  Dispensing Limits

All drugs may be dispensed in a 30-day supply with a maximum of 400 units.  Seventy-five percent (75%) of the days' supply must elapse before the prescription can be refilled.  (A prescription can be refilled at 22 days.)  The following are exceptions:

IX.  Mandatory Generic Substitution

Generic substitution is mandatory when a generic equivalent is available.  All branded products that have 3 or more A-rated generic equivalents will be reimbursed at the maximum allowable cost.  The mandatory generic substitution provision is waived for the following four products due to their narrow therapeutic index: Coumadin, Dilantin, Lanoxin, and Theodur.

X.  DESI Drug Explanation

DESI drugs are an exclusion for the Scrip Pharmacy Solutions/TLC program.

DESI drug products and known related drug products are defined as less than effective by the Food and Drug Administration because there is lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established.  The Health Care Finance Administration (HCFA) does not allow for reimbursement of these drugs.

72-hour emergency supply of medication for this member. If Scrip Pharmacy Solutions is unable to locate a Medicare provider in your area, or if the member has a transportation problem, an override will be placed in the appropriate claims processing system, which will allow reimbursement for one month of medication for this member.

XI. Health Industry Numbers

TLC utilizes Health Industry Numbers (HIN) for the pharmacy network. For all TLC Prescriptions, please use valid HIN numbers only.  For prescriptions without HIN numbers, please call Scrip Pharmacy Solutions at 1-800-230-8189.

XII. Where to Call

PHYSICIANS

Formulary Questions:
Scrip Pharmacy Solutions                                                          (800) 762-2299

Medical Necessity:
Scrip Pharmacy Solutions                                                          (800) 762-2299

Prior Authorization:
Scrip Pharmacy Solutions                                                          (800) 762-2299

PHARMACISTS

Provider Network Questions:
Scrip Pharmacy Solutions                                                          (800) 230-8187

Claims Processing Customer Service:
Scrip Pharmacy Solutions                                                          (800) 213-5640

SUBSCRIBERS

Subscriber Questions:
Should be directed to the subscriber's MCO or Physician.

XIII. TLC Phone Numbers for Member Services

TLC Family Care Health Plan                                          (800) 473-6523

XIV. TLC Contacts for Medical Appeals

In the event that a patient and/or physician disagrees with the decision regarding coverage of a medication, the physician may appeal the decision in writing to the Clinical Coordinator at Scrip Pharmacy Solutions via fax at (800) 354-5979.  In the event that the patient and/or physician disagrees with the decision of the Clinical Coordinator, the physician may then appeal this decision in writing to Marilyn Lee, Pharm D., Pharmacy Director at the following address and fax:                  

TLC
Regional Medical Center
877 Jefferson Street
Memphis, TN 38103
FAX (901) 545-7351

XV. Annotations