Prior Authorization Forms
Frequently Asked Questions
Below are some frequently asked questions and other information about our prescription drug formulary listings, including information on requesting exceptions and transition of care between health plans.
What if my prescriptions are not listed?
If you have any questions, please call Optima Community Complete Member Services.
If you learn that Optima Community Complete does not cover your drug, you have two options:
- You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Optima Community Complete.
- You can ask us to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the Optima Community Complete Formulary?
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Optima Community Complete limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You or your prescriber should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you or your prescriber request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You or your prescriber can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
Medication Therapy Management Program
Better therapeutic outcomes for members with multiple conditions
Our Medication Therapy Management Program (MTMP) is focused on improving therapeutic outcomes for Medicare Part D members. This program is administered by OptumRx®, our pharmacy benefits manager. Optima Community Complete members can participate in this program at no cost. There is no change to insurance benefits, co-pays/coinsurance, prescription coverage, or available doctors or pharmacies while in this program.
To qualify for MTMP, a member must meet all of the following criteria:
- Members must have filled (4) four or more chronic Part D medications; and
- Members must have at least (2) two of the following chronic conditions — Asthma, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Depression, Diabetes, Dyslipidemia, HIV/AIDs, Hypertension, Osteoporosis, and Rheumatoid Arthritis; and
- Members must be likely to incur annual costs of $3,967 in 2018 (or $4,044 in 2019) or more for all covered chronic Part D medications.
The success of our MTMP is built upon our proven experience using a wide range of services designed to help members with multiple conditions by:
- Ensuring they take their medications correctly
- Improving medication adherence
- Detecting potentially harmful medication uses or combinations of medications
- Educating members and health care providers
Our programs are evidence-based and can integrate both pharmacy and medical data, when available, and are built upon multiple measures that demonstrate positive clinical outcomes for members like you. Pharmacists, physicians and PhDs develop, manage and evaluate the programs for effectiveness.
One-on-one consultations between our clinicians and members are also an important part of our MTMP. Such consultations ensure that members are taking their medications as prescribed by their health care provider.
Comprehensive Medication Review (CMR)
The Centers for Medicare & Medicaid Services (CMS) requires all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of MTMP. If you meet the criteria outlined above, you will receive an MTMP Enrollment Mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over-the-counter (OTC), herbal therapies and dietary supplements), which is intended to aid in assessing medication therapy as well as optimizing outcomes. Also, MTMP-eligible members will be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which members’ prescribers may receive a member-specific report.
The CMR includes three components:
- Review of medications to assess medication use and identify medication-related problems. This may be conducted person-to-person or "behind the scenes" by a qualified provider and/or using computerized, clinical algorithms.
- An interactive, person-to-person consultation performed by a qualified provider at least annually to all MTM-eligible members.
- An individualized, written summary of the consultation for the member, including but not limited to, a personal medication list (PML), reconciled medication list, action plan, and recommendations for monitoring, education, or self-management.
If you have any questions about the MTM program, please call the OptumRx MTM Department at 1-866-352-5305, Monday - Friday, 8 am to 8 pm CST. TTY users call 711.
Utilization and Quality Assurance Program
Optima Community Complete works with physicians to make sure members get the most appropriate, safe and cost-effective drugs. The plan's Utilization Management and Quality Assurance program is designed to assure adverse drug events and drug interactions are avoided and ensure optimum medication use. The Utilization Management and Quality Assurance program is provided at no additional cost to members or providers.
Utilization Management and Quality Assurance programs incorporate tools to encourage appropriate and cost-effective use of Part D drugs. These tools include prior authorization, quantity limits, additional charges and clinical interventions. Other tools may be used if necessary.
- PA = Prior Authorization. Our Plan requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, Optima Community Complete may not cover the drug.
- ST = Step Therapy. In some cases, we require you to first try certain drugs to treat your medical condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
- QL = Quantity Limits. For certain drugs, our Plan limits the amount of the drug that it will cover. This may be in addition to a standard one-month or three-month supply.
See Optima Community Complete's formulary for drugs that have prior authorization requirements, step therapy, or quantity limits.
As part of the Utilization Management and Quality Assurance program, all prescriptions are screened by systems to detect and address the following:
- drug-drug interactions that are clinically significant
- duplication of drugs (taking more than one drug in the same drug class)
- inappropriate drugs
- incorrect drug
- patient-specific drug contraindications
- over-utilization of drugs
- under-utilization of drugs
- abuse or misuse of drugs.
A review of prescriptions is performed before the drug is dispensed. These are concurrent drug reviews and are clinical edits at the point-of-sale (at the pharmacy counter).
Retrospective drug utilization reviews identify inappropriate or medically unnecessary care. Optima Community Complete performs periodic reviews of claims data to evaluate prescribing patterns and drug use that may indicate inappropriate use.
Physicians treating patients who are receiving potentially inappropriate drug therapy will receive provider-specific reports detailing the patient's drug utilization. The providers receive educational materials explaining the report and the intervention it addresses. The reports identify individual patients who may require evaluation, the reason for the report and options for the provider to consider.
Transition Process Information
When you join our Plan as a new member, you may be taking drugs that are not on our formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. You should talk with your doctor to determine what is best for your care. During the first 90 days of your new membership, we may provide a temporary supply of a drug which is not on our formulary or which has restrictions. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary refill supply for the drug during the first 90 days of the new plan year.
We will provide a temporary 31-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy for a Part D drug that is not on our formulary or that is subject to restrictions, such as prior authorization or step therapy. You can only receive one temporary 31-day supply as part of our transition process. After you receive the temporary 31-day supply, we will provide you with a written notice explaining the steps you can take to request an exception and how to work with your doctors if you should switch to a drug we cover.
For Members in a Long-Term Care Facility (like a nursing home)
If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary transition supply (unless you have a prescription written for fewer days). The first supply will be for a maximum of 98-days, or less if your prescription is written for fewer days. If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan, when that member is a resident of a long-term-care facility. If a new member, who is a resident of a long-term-care facility and has been enrolled in our Plan for more than 90 days, needs a drug that isn’t on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 34-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception. This is in addition to the initial transition supply provided.
If a current member transitions to a different level of care, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days) and cover more than one refill during the first 90 days if the member transitions into a long-term care facility. If the transition is out of a long-term care facility, we will cover a temporary 31-day supply (unless the prescription is written for fewer days) when the member goes to a network pharmacy (and the drug is otherwise a “Part D drug”). After we cover the temporary 31-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
Last Updated: 6/17/2019