Pharmacy Utilization Management Programs
Executive Overview
October 2012
Pharmacy Utilization Management
• The purpose of this document is to provide an overview of
Responsible Rx, Florida Blue’s pharmacy utilization
management program.
• The document includes following:
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Program descriptions
How these programs work
Frequency of program changes
Member notifications, when impacted by program changes
Authorization requests
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Responsible Rx Programs
Responsible Rx is the name of Florida Blue’s pharmacy Utilization
Management Program created to support affordable solutions by delivering
integrated pharmaceutical and medical services in an optimized manner for
our members.
Responsible Rx includes the following:
• Prior Authorization
• Responsible Steps
• Responsible Quantity
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Prior Authorization
• The prior authorization program encourages the safe and
cost-effective use of medication. Under this program, certain
high-cost drugs that have the potential for misuse require prior
authorization through Florida Blue before they will be covered
under your prescription drug plan. If a member is currently
taking or is prescribed a drug that is included in the prior
authorization program, the physician will need to submit a
prior authorization request in order for the members
prescription to be considered for coverage. As always,
treatment decisions rest solely with the member and their
doctor.
• Program savings average $0.50 to $0.75 PMPM
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If you’ve tried the alternative drugs and your doctor still wants you to use one of the drugs listed in the program, the prescription will be filled. .
Prior Authorization Program in Action
How Prior Authorization Works
If a member is taking a medication that is included in the prior authorization program,
the members physician will need to submit a prior authorization request for the
current prescription before the member can continue to receive coverage for the
drug. If a members doctor writes a new prescription for a medication included in the
program, he or she will need to complete and submit a prior authorization request
before the drug can be covered under the benefit plan.
If the prior authorization request is approved:
The member will pay the appropriate amount based on the
prescription drug benefit.
If the prior authorization request is not approved:
The medication will not be covered under the prescription drug benefit. The
member can still purchase the medication, but will be responsible for the full cost.
Or, the member can talk to their doctor to find out if another drug might be right for
them.
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Responsible Steps
• Responsible Steps is a step therapy program that offers a
“step” approach to providing medications to ensure the use of
a covered alternative or prerequisite drug first before
coverage of the drug included in the Responsible Steps
program is provided. This means that a member may first
need to try a more cost-effective or clinically appropriate
medication before certain high-cost medications are approved
by Florida Blue. Responsible Steps is based on nationally
recognized therapeutic guidelines, clinical evidence, and
research. Prescription medications included in the
Responsible Steps program are not covered unless a member
has tried one or more covered alternative medications first.
• Program savings average $1.00 to $1.50 PMPM
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If you’ve tried the alternative drugs and your doctor still wants you to use one of the drugs listed in the program, the prescription will be filled. .
Responsible Steps in Action
How Step Therapy Works
A member has high
cholesterol and their doctor
writes them a prescription for
Lipitor.
The member goes to the
pharmacy and the pharmacist
enters the prescription into the
system, and we check the
members claims history.
If the member has tried the alternative
drugs and your doctor still wants you to
use one of the drugs listed in the
program, the prescription will be filled.
If the member hasn’t tried the alternatives, the
pharmacist will ask them to discuss it with their
doctor. The doctor can either prescribe an
alternative or request an exception from us.
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Responsible Steps in Action
Potential Member Cost Savings
Self Administered
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Responsible Quantity
• The Responsible Quantity Program is a coverage maximum
program that encourages the appropriate, safe and costeffective use of medication by setting a maximum quantity per
month for a medication or supply. The program places
coverage maximums on select medicines. The quantity
limitations used in our Responsible Quantity program are
based on the Food and Drug Administration’s guidelines and
the manufacturer's dosing recommendations.
• Program savings average $0.20 to $0.30 PMPM
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If you’ve tried the alternative drugs and your doctor still wants you to use one of the drugs listed in the program, the prescription will be filled. .
Responsible Quantity in Action
How Quantity Limits Works
A member has high
cholesterol and their doctor writes them a
prescription for 45 tablets of 80 mg Lipitor.
The member goes to the pharmacy and
the pharmacist enters the prescription into
the system. We automatically check the
members claim history before authorizing
the pharmacy to fill the prescription.
If the members prescription exceeds the
maximum dose allowed for a 30-day
supply, the pharmacist will receive a
message indicating “exceeds plan limit”.
The system will also tell the pharmacist
the quantity that is allowed for coverage.
If the member chooses to have a quantity greater
than the allowed coverage maximum, they will be
responsible for the full out-of-pocket cost of the
additional non-covered quantity. If the member
requires a greater monthly quantity than the
coverage maximum based on medical necessity, the
members doctor can submit an authorization request
for coverage of the prescribed quantity and dosage.
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Responsible Rx Program Updates
and Formulary Changes
Our panel of Physicians and Pharmacist review new and existing drugs
quarterly and evaluate the following:
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Should we cover and what is the appropriate tier for new drugs entering the market?
Are there any safety concerns with any of the drugs on our formulary?
There are varying reasons why changes are made to the medications listed in
the Medication Guide.
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The tier level of a Brand prescription medication included on the Medication List may
increase (change from Tier 2 to Tier 3) when an FDA-approved bioequivalent Generic
prescription medication becomes available.
Newly marketed Brand prescription medications are usually introduced on Tier 3 until the
opportunity exists to review the medication level, at which time a determination will be made
as to which tier will apply based on safety, efficacy and the availability of other products
within that class of medications
Formulary changes are reflected in the Medication Guide bi-annually (January and July)
along with bi-annual update lists (April and October). Both can be found on the Florida BlueL
website.
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Authorization Forms
• Prior authorization request forms are available on the provider
website at www.bcbsfl.com under For Providers, then Pharmacy,
and the Prior Authorization Program Information and Authorization
forms link.
• Responsible Steps program authorization request forms are
available on the provider website at www.bcbsfl.com under For
Providers, then Pharmacy, then the Responsible Steps Program
Information and Authorization Forms link.
• Members requiring a greater monthly quantity than the coverage
maximum based on medical necessity can have their physician
submit a prior authorization request by filling out the Quantity Limit
Prior Authorization Form at www.bcbsfl.com, under For Providers,
then Pharmacy then the Quantity Limit Authorization form link.
Note: Authorization forms must be completed and submitted by the prescribing physician. Submission of an authorization
form does not constitute nor guarantee approval as specific criteria must be met before approvals are granted. Each
request is subject to review based on the criteria specific to each program.
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Sample Member Notification
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Appendix
Accessing Authorization Forms
Authorization request forms are available at www.bcbsfl.com under For Providers, then Pharmacy.
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