Wellmark's Therapeutic Categories

Phansalkar, S., Her, Q. L., Tucker, A. D., Filiz, E., Schnipper, J., Getty, G., & Bates, D. W. (2015). Impact of incorporating pharmacy claims data into electronic medication reconciliation. American Journal Of Health-System Pharmacy, 72(3), 212-217 6p. doi:10.2146/ajhp140082

Finally, in a February 2012 proposed regulation, CMS proposed that state Medicaid agencies reimburse pharmacies for retail drugs based on actual acquisition cost. CMS recognized, however, that states may not be able to determine the actual price paid by a pharmacy for a drug billed to Medicaid, so it suggested that states survey pharmacies or rely on other data to calculate an average acquisition cost for drugs purchased and billed by retail community pharmacies. The article reviewed the association between benefit caps, prescription drug use, and the costs associated. It also detailed drug cost sharing, additional medical costs, and specific health outcomes. Using observational data, the studies analyzed the changes and did a cost comparison of outcomes at two points of time, before and after the pharmaceutical benefits changed. The article detailed the impact of pharmaceutical drugs was often difficult to analyze because some data analyzed utilization while others analyzed actual pharmaceutical spending. The data surrounding utilization compared as many as five factors such proportion

Within the formulary the drugs are divided into tiers. Co-payments are based on the tier that the drug is in and range from tier 1, the least expensive drugs, to tier 3 the most expensive drugs. Each insurance company plan is allowed to add or drop drugs from their formularies and move drugs from one tier level to another throughout the year. An insurance company can also drop a drug in the middle of the year, but must continue covering the drug for anyone taking it until the next reenrollment period, at which time a new plan will have to be chosen that covers that drug (Gustaitis, 2007). Although not used a lot there is a fourth tier that is for specialty drugs only. Some plans use a flat-rate or assign a percentage co-pay to the higher tier drugs (Gustaitis, 2007). Other characteristics of the insurance company plans that they have control over are requiring prior authorization for a drug, using step therapy, limiting the quantity, participating at certain pharmacies, and having preferred pharmacies (Gustaitis, 2007).

The Medication Policy and procedure and Mars Handbook covers assessment of individuals’ needs, administering, storage, recording and disposal of medicines including their effects and potential side effects

The generic prescription drugs that Plan A provides Impatient RX and does not give Outpatient RX. In Plan B, the generic prescription drugs are not covered. I would take generic prescription drugs for less serious illnesses such as headaches and pain. The Brand Prescription Drugs for Plan A are impatient RX are covered and Outpatient RX is not covered. Plan B’s Brand Prescription Drugs are not covered. Brand Prescription Drugs are medications that I would use for minor illnesses that are branded and patented by a company.

However, changing perceptions of prescribers and consumers will be necessary to launch the initiative. The education of providers regarding the therapeutic equivalent and efficacy of generic medications are therapeutic substitutes is very important—prescribers will be the driving force behind adoption of generics over brand-name drugs. The use of e-prescribing provides information regarding cost, formularies and available generics at the fingertips of providers (United States Department of Health and Human Services, 2010).

Drugs that treat serious illnesses are fully covered while drugs that treat non-life-threatening illnesses and have little medical benefit get 15% coverage. Finally, drugs that don’t have enough evidence behind them aren’t covered at all while most drugs get 65% coverage

Each plan is also followed by a detailed chart that breaks down which tier each medication falls under, estimated full drug cost at each pharmacy, whether any special actions are to be taken to receive the medication. There are 5 tiers that these medications can fall into, and with each plan these medications either fall into tier 3, 4, or 5. Tier 3, also known as preferred brand, are brand-name drugs that don’t have a generic equivalent. Tier 4, also known as non-preferred brand, are the higher-priced brand-name and generic drugs not in a preferred tier. Tier 5, also known as specialty, are the most expensive drugs on the drug list. Looking at drug coverage information and the estimated full drug cost at a retail pharmacy for each plan, it

Five different levels of classification for approved prescription medicines are included in the formulary; drugs in lower tiers cost the patient less than those listed in higher brackets. Medicare plans and patients copay for drugs, if a pharmacist decides that a drug listed in a higher bracket is needed over one listed in the lower price range, the patient can file an exception with the plan, as reported by medicare.gov.

In sixth grade I began my monthly visit to the Cleveland Clinic Main Campus hospital. While other kids my age were at Girl Scouts, playing volleyball, or getting manicures, I was driving an hour to get treatment. I remember my peers asking, why are your fingers wrapped? Why do you have red marks on your face? My eyes would go wide, like a deer caught in headlights, “my dog scratched me”, I would stutter out. I was embarrassed to admit to them that I had warts. Still, almost eight years later, hearing the word “warts” makes my stomach churn and hands sweat. When I think of the word, the first thing that comes to mind is an ugly witch with a mammoth wart on her nose, which was how I pictured I appeared to other people- more importantly, it was how I pictured myself.

Agent went over the drugs that the consumer gave her to look up that was important to him as well as the most expensive drug. The original plan that he was looking for did not cover that drug, but the enhanced plan did even though it was a higher monthly premium

If the Pharmacy is in the Network and the Drug is attached, claim rejects with Reject 70 - Plan Exclusion.

A drug formulary is a list of prescription medications that a health insurance plan will cover. Each insurance plan has its own formulary of covered prescriptions. Formularies are guidelines of how an insurance company is going to share the cost of medications with its customers. Drug tiers determine how much the medication will cost. Sometimes there are co-payments and for specialty drugs, there may be a coinsurance payment. Some medications require that your doctor receive prior authorization, otherwise you will have to pay the full amount. There are quantity limits on some medications as the insurance companies have determined that too much of certain drugs can be a safety concern, such as opioids. If you pay full price you can still receive

Based upon our review, it has been determined that you are enrolled in MediBlue Plus (HMO) The plan’s grievance department received your concerns regarding your provider/Hospital not being in-network with your plan. You also stated that you are unhappy that when you went to get your Lorezapam filled the pharmacy only gave you 102 pills.

Under the medications tab, the system offers the user with a wide variety of editable selections when entering medications. This would allow the user to feel in control and not limited in their documentation.