Note: This section applies only to QualChoice members who have OptumRx (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 QualChoice clinical staff. Drugs and drug classes are reviewed for safety, efficacy, comparability to other products on the market and cost, in that order. Accepted drugs are placed into one of several tiers after further review by our clinical staff. Drugs not adopted into coverage are not covered by QualChoice.

Pre-authorization (PA)

Some drugs are covered only if pre-authorized (Pre-authorization List; select Medications). 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 QualChoice clinical staff with review by the P&T Committee and the Medical Advisory Committee.

For drug pre-authorization, contact OptumRx, our pharmacy benefit manager, at 877.629.3118.

Step/Contingent Therapy

Medications 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 that the safest, most cost-effective medications are tried before more expensive options. Contingent therapy means a drug is approved only if another drug is being used concurrently. When at all possible, these edits are programmed into the claims adjudication system. The member’s pharmacy history is reviewed to ensure compliance with the requirement. If this review does not show compliance, the drug will require pre-authorization.

Quantity Limits

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 noted by (QL) beside the drug or drug category in 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.

Appeals

Members have the right to appeal any adverse pharmacy benefit decision by QualChoice. The prescriber, acting on behalf of the member, may file the appeal.

New-to-Market Medications

Drugs new to the 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.

Formularies, Forms and Information

For current drug formularies, forms and additional pharmacy information, see Pharmacy and Drug Formulary page.