Formulary management

Formulary management procedures

The Prevea360 drug formulary is reviewed every month. With the approval of newer generic drugs, changes and updates are made on a regular basis. In addition to updating the formulary status of covered drugs, formulary restrictions are also modified as necessary.

Here is an update of restrictions and limitations associated with the drug formulary:

  • Closed formulary. Prevea360 employs a closed formulary. If a drug is not listed on the drug formulary, the product is not covered by the member’s pharmacy benefit. If the member chooses a product not on the formulary, the member is responsible for 100 percent of the cost of the drug.

  • Mandatory generic substitution. If a drug is available in a generic version, Prevea360 may require the use of the generic version. If the generic version of the drug is mandated and the patient chooses to receive the branded version, the patient is responsible for the highest tier branded copay plus the ingredient cost difference between the brand and generic versions. If the patient’s physician requests the branded version, the patient is only responsible for the highest tier branded copay.

  • Prior authorization. When a drug is prior authorized, the physician must receive approval prior to prescribing the drug. The list of prior authorized drugs and the request forms are available on prevea360.com at For Members > Pharmacy Benefits.

  • Step therapy. Step edits are often used within a therapeutic class to require generic or preferred drug use prior to a non-preferred drug. When a step edit is in place, the patient must have trialed therapy with a preferred drug(s) prior to receiving approval for the non-preferred drugs. Step edits are completed point-of-service at the pharmacy, and there are no prior authorization requirements.

 



Step therapy is a formulary tool used to manage high-cost medications while improving health. When a medication requires step therapy, you are encouraged to try a less costly, clinically equivalent drug first. After trying this therapy, you can work with your prescriber to decide what is best for you.
 
You and your prescriber may find that the lower cost medication works well. If the medication isn’t working or your need is medically necessary, please ask your prescriber to contact us.
Step therapy is an effective tool for ensuring that you receive safe, effective, high-quality medications at a lower cost.

A Pharmacy and Therapeutics Committee is used to make all drug therapy decisions, including step therapy. They evaluate the safety and efficacy of a product, including clinical practice guidelines, based on available medical literature.
 
Priority is put on current U.S. guidelines that:

  • acknowledge any potential conflict of interest
  • describe the methodology of guideline development
  • emphasize inclusion of peer-reviewed publications and evidence-based research
  • incorporate widely-accepted medical practice

 

When higher-quality guidelines are unavailable, we consider others which:

  • come from organizations outside the U.S.
  • focus primarily on expert or consensus-based opinion
  • lack any of the areas mentioned above

 

The committee considers cost only after it makes the clinical determination. Once the medication is evaluated, if a lower cost alternative exists, a step therapy protocol is set up.



  • Specialist restrictions. Specialist restrictions limit the prescribing of a drug to a unique specialty. These decisions are based on the indications and uses for the specific drug.

  • Quantity level limits. Quantity level limits restrict the supply of drug product that may be dispensed either per prescription or per a specific amount of time.

  • Specialty pharmacy. If a drug is available or mandated to be dispensed by a specialty pharmacy, the specialty pharmacy designation will be applied.