NOTE: The Pharmacy section only applies to QualChoice risk and/or TPA members who have 'Optum Rx' (formerly Catamaran) listed as the pharmacy benefit manager on their QualChoice ID card.
QualChoice uses a number of different strategies to promote the safe and appropriate use of prescription drugs. These strategies include the use of the Preferred Drug List (PDL)/Formulary, along with utilization management edits such as pre-authorization, quantity limits, step/contingent therapy, and specialty drug management.
Preferred drugs are chosen based on the guidance of the QualChoice Pharmacy & Therapeutics (P&T) Committee. The committee is composed of practicing Arkansas physicians and pharmacists along with the QualChoice clinical staff. Drugs and drug classes are reviewed based on safety, efficacy, in comparison to other products on the market, and cost, in that order. Drugs that are adopted into coverage based on P&T review are placed into one of the tiers on the PDL after further review by our clinical staff. Drugs not adopted into coverage are not covered by QualChoice.
Some drugs are covered only if pre-authorized (select 'medications' in the pre-authorization list). In the PDL these drugs are noted by (PA) beside the drug or drug category. Drugs requiring pre-authorization are reviewed based on clinical criteria developed by the QualChoice clinical staff with review by the P&T Committee and the Medical Advisory Committee.
For drug pre-authorization contact Optum Rx, our Pharmacy Benefit Manager, at 877.629.3118.
Medication requiring step or contingent therapy are noted by either (ST) or (CT) in the PDL. Step therapy means that a certain drug requires use of another drug first, before it is covered. The intent of a step therapy edit is to ensure the safest, most cost-effective medications are used prior to more expensive options. Contingent therapy means a drug is only approved if another drug is being used concurrently. When at all possible, these edits are programmed into the claims adjudication system and utilize a ‘look back’ to determine compliance with the requirement by reviewing the pharmacy history. If this ‘look back’ is unable to determine compliance, the drug will require pre-authorization.
Quantity limits ensure the safe and appropriate use of select medications by covering a specific amount that can be dispensed at one time. Quantities greater than the specified amount require pre-authorization for coverage. Drugs with quantity limits are signified by (QL) beside the drug or drug category on the PDL.
Specialty Pharmacy Management
Specialty drugs require special handling, are used to treat complex or rare health problems, and are very costly. These drugs, including both oral and injectable products, are dispensed by our preferred specialty pharmacy, BriovaRx. Specialty drug coverage may vary by plan.
Contact BriovaRx at 866.791.8679.
Members have the right to appeal any adverse benefit decision by QualChoice. The prescriber, acting on behalf of the member, may also file the appeal.
New drugs to market are not covered by QualChoice until reviewed by the P&T Committee. Generally, all new drugs are reviewed within six months of market entry.