For MVP members who have a prescription drug benefit as part of their health coverage, we have a drug Formulary which is our approved list of covered medications. All medications on our Formulary have been proven to be safe and effective by the Food and Drug Administration (FDA) and are covered in the best interests of our members.

Here are answers to some of the questions you may have about the list of covered medications.

Drug Coverage

• What drugs does MVP cover?
  
• How does MVP decide which drugs to cover?
• Are new drugs covered?
• What if my doctor says I need a drug that MVP does not cover?
• If I pay out-of-pocket for my medication, will I be reimbursed?

Tiered Drugs

• Why are prescription drugs divided into tiers?
• What is the difference between tiers?

Pharmacy Management

• Are there drugs that require prior approval before MVP will pay for them?
• Are there drugs that require step therapy or have quantity limits on them? 

Pharmacy Partners

• Who is Medco?
• What is a Specialty Pharmacy?

What drugs does MVP cover?
The Formulary, our approved list of medications, includes thousands of drugs, both generic and name-brand. It is a comprehensive guide that is developed based on sound clinical evidence and is a reflection of current treatment guidelines and community practice standards. Drugs on the Formulary have been approved by the Food and Drug Administration (FDA) and are considered to be safe and effective.  In the cases where we do not cover a certain drug, we usually cover an alternative drug. To find a specific drug on the Formulary, use our Rx Search. MVP offers different types of formularies. Review your benefit plan documents for a complete description of your pharmacy benefit.

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If I pay out-of-pocket for my medication, will I be reimbursed?

You may submit your detailed receipt and the completed Medco Reimbursement Form directly to Medco for reimbursement consideration. If approved, payment will be made based on the pharmacy network rate minus your copayment or coinsurance.

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How does MVP decide which drugs to cover?
Decisions on which drugs are covered are made exclusively by the Pharmacy and Therapeutics (P&T) committee, which is comprised of primary care and specialty physicians, pharmacists and other health care professionals from our community. The committee is dedicated to selecting drugs for our Formulary based on the role they play in treating a specific disease or condition and those that provide the greatest value to our members. The P&T committee also determines the copay tier for each drug.

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Why are prescription drugs divided into tiers? 

Each medication is placed into a tier according to how it compares with other drugs that are used to treat the same disease or condition. Medications are divided into different tiers to provide options to our members and prescribing doctors. Rather than only covering a select number of medications, tiering allows MVP to cover most medications at different cost shares or copays.

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What is the difference between tiers?

Each tier has a copay level for covered prescription drugs within that tier. Your employer or health plan sets the copays for the drugs covered under your pharmacy benefit.

• Tier 1 is your lowest copay choice and usually includes generic drugs that meet MVP Health Care guidelines for a Tier 1 drug.
  
  
• Tier 2 is your mid-range copay choice and includes covered brand-name drugs that have been selected as Tier 2 drugs because of their overall value. Consider Tier 2 drugs if you and your doctor decide that no Tier 1 medication is right for you.
  
  
• Tier 3 is your highest copay choice and includes all other covered prescription drugs - generic and brand name. It also includes those that are not on the prescription drug list, and new drugs that are being reviewed.

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Are new drugs covered?
MVP wants to ensure that members have access to the latest advances in medicine. At each P&T meeting, new prescription drugs are reviewed for potential addition to our covered list of medications. All new drugs, which include but are not limited to, new chemicals, new dosage forms, combinations of approved drugs or drugs with potential safety and/or efficacy issues require prior authorization for a minimum of six (6) months from when they become available. New drugs are placed in the highest copay tier during this prior authorization period.

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What if my doctor says I need a drug that MVP does not cover?
We place great confidence in the clinical decisions of our participating physicians and acknowledge that there are instances where a drug that is not covered may be required for appropriate care. In such cases, MVP may grant a Formulary Exception based on medical necessity through our prior authorization process.

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Are there drugs that require prior authorization before MVP will pay for them?
Yes, some drugs require prior authorization to be covered. Policies that list the criteria under which a medication would be approved are in place. The Formulary identifies those drugs that require prior authorization. You can also search our database for this information, or contact our Customer Care Center at the phone number listed on your identification card.

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Are there drugs that require step therapy or have quantity limits on them? 

Yes, some drugs are subject to step therapy or have quantity limits on them.

Step therapy is a pharmacy management program that requires members to try a less expensive, clinically equivalent drug before providing coverage for a more expensive drug.  For example, if Drug A and Drug B both treat your medical condition, MVP may not cover drug B unless you try Drug A first.  If Drug A does not work for you, MVP may then cover Drug B subject to prior authorization. Targeting specific classes of drugs can help improve generic and formulary dispensing rates and maximize plan and member savings. Step therapy edits are supported by pharmacy policies. The Formulary identifies those drugs that require step therapy.

Quantity limits are in place for a number of medications that have potential for significant overuse, misuse, waste, or abuse.  Based on FDA or manufacturer’s guidelines and/or the recommendations of the P&T committee, this program ensures that members receive only the recommended safe quantities of select medications. The Formulary identifies those drugs that are subject to quantity limits.

For more information on step therapy and quantity limits, contact our Customer Care Center at the phone number listed on your identification card.

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Who is Medco?

To ensure high quality, cost-effective pharmacy programs, MVP has chosen to partner with Medco Health Solutions, Inc. Medco works jointly with MVP’s participating physicians and pharmacists to ensure that prescription drug therapy is safe, effective and an appropriate component of a member’s overall health care. In addition, Medco adjudicates claims at the pharmacy, provides home delivery (mail order) services and assists in formulary and policy development, implementation and maintenance.

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What is a Specialty Pharmacy?

Certain medications require providers and/or members to obtain them through an exclusive vendor. MVP Health Care has partnered with CuraScript as our exclusive vendor for select, high cost injectable and oral medications including but not limited to: Multiple Sclerosis, Growth Hormones, select Hepatitis C medications and Rheumatoid Arthritis therapies.The Formulary identifies those drugs that must be obtained from CuraScript. To find out more about CuraScript, visit their Web site at www.curascript.com for additional information.

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