Pharmacy and prescription drugs

pharmacy and prescription drugs
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2020  |  2019

  • Formulary 2020
  • Medication therapy management program 2020
  • Drug coverage determinations 2020
  • Exceptions, limitations and coverage determinations 2020
  • Part D transition program 2020
  • Quality assurance policy 2020
Formulary information

Sharp Direct Advantage provides Medicare prescription drug coverage under an approved formulary. The formulary or drug list is a list of covered drugs provided by Sharp Direct Advantage. The formulary drugs are selected because they are believed to be a necessary part of a quality treatment program.

Sharp Direct Advantage covers both brand name and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. The formulary is updated regularly. Please review your prescriptions to ensure they are covered.

Our drug list is updated on a monthly basis. For more recent information or an updated list of drugs, please contact our Customer Care team by dialing our toll-free number: 1-855-562-8853 (TTY/TDD users can dial 711) during the following times:

Date Days Hours
  October 1 - March 31   7 days a week   8 am to 8 pm
  April 1 - September 30   Monday through Friday   8 am to 8 pm


Search/view the 2020 drug list

How to use the online search tool

To search for a specific drug using the online search tool, type the name of the drug into the search box. A drop-down list will appear with a list of drugs from which you can select your desired drug. Once selected, click on the red "Add to List" button. A table will appear from which you can view your drug's information.


How to use the PDF drug list

To search for a specific drug in the PDF, press control (CTRL) and "F" on your keyboard. A search box will appear in the top right corner of your browser where you can enter the name of the drug you are looking for.


Search online drug list  View drug list (PDF)  View drug list in Spanish (PDF)


What is the medication therapy management program?

The Sharp Direct Advantage medication therapy management program (MTMP) helps members get the greatest health benefit from their medications by:

  • Preventing or reducing drug-related risks
  • Increasing your awareness
  • Supporting good habits
As part of the MTMP, qualified members receive a one-on-one medication review with a pharmacist or licensed pharmacy intern under the direct supervision of a pharmacist followed by targeted medication reviews on a quarterly basis. The program is offered to you at no extra cost. This MTMP is not considered a benefit.


Who qualifies for the program?

Sharp Health Plan automatically enrolls you in the Sharp Direct Advantage MTMP at no cost to you if you meet all three conditions:

  1. You take eight or more Medicare Part D covered maintenance drugs
    AND
  2. You have three or more of these long-term health conditions:
    • Asthma
    • Chronic obstructive pulmonary disease
    • Diabetes
    • Depression
    • Osteoporosis
    • Chronic heart failure
    • Cardiovascular disorders such as high blood pressure, high cholesterol or coronary artery disease
    AND
  3. You reach $4,255 in yearly prescription drug costs paid by you and the plan.
Your participation is voluntary, and does not affect your coverage. The program is no cost to you and is open only to those who are invited to participate. The program is not a benefit for all plan members.


What services are included in the program?

The Sharp Direct Advantage MTMP provides you with a:

  • Comprehensive medication review
  • Targeted medication review

Comprehensive medication review

The review is a one-on-one discussion with a pharmacist, to answer questions and address concerns you have about the medications you take, including:

  • Prescription drugs
  • Over-the-counter (OTC) medicines
  • Herbal therapies
  • Dietary supplements and vitamins

The pharmacist will offer ways to manage your conditions with the medications you take. If more information is needed, the pharmacist may contact your prescribing doctor. The review takes about 30 minutes and is usually offered once each year – if you qualify. At the end of your discussion, the pharmacist action will provide you with a personal medication list with the medications you discussed during your review.

You will also receive a medication action plan. Your plan may include suggestions from the pharmacist for you and your doctor to discuss during your next doctor visit.

Here is a blank copy of the personal medication list for tracking your prescriptions. Please use the form to keep track of all your prescriptions and other-the-counter medications.

Targeted medication review

With this review, we mail, fax, or call your doctor with suggestions about prescription drugs that may be safer, or work better than your current drugs. As always, your prescribing doctor will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your doctor decide to change them. We may also contact you, by mail or phone, with suggestions about your medications.


How will I know if I qualify for the program?

If you qualify, we will mail you a letter. Your letter will give you an explanation of the program and gives you instructions if you want to opt-out of the program. Also, you may receive a call, inviting you to participate in this one-on-one medication review.  


Who will contact me about the review?

You may receive a call from a pharmacy where you recently filled one or more of your prescriptions. You will be given the option to choose an in-person review or a phone review.

You may be contacted by a call center pharmacist to provide your review, and ensure that you have access to the service if you want to participate. These reviews are conducted by phone.


Why is a review with a pharmacist important?

Different doctors may write prescriptions for you without knowing all the prescription drugs and/or OTC medications you take. For that reason, a pharmacist will:

  • Discuss how your prescription drugs and OTC medications may affect each other
  • Identify any prescription drugs and OTC medications that may cause side effects and offer suggestions to help
  • Help you get the most benefit from all of your prescription drugs and OTC medications
  • Review opportunities to help you reduce your prescription drug costs


How do I benefit from talking with a pharmacist?

  • Discussing your medications can result in real peace of mind knowing that you are taking your prescription drugs and OTC medications safely
  • The pharmacy can look for ways to help you save money on your out-of-pocket prescription drug costs
  • You benefit by having a personal medication list and a medication action plan to keep and share with your doctors and health care providers


Call with questions

To learn more or get additional information, please contact us.


Exceptions & prior authorization

Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing doctor’s supporting statement. You can request an expedited (fast) request 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 your prescriber’s or prescribing doctor’s supporting statement.

Exceptions are also called coverage determinations. Members can request an exception to the Sharp Direct Advantage cost-sharing structure, to the formulary, or to obtain a formulary drug that is subject to a utilization management restriction (e.g., step therapy, prior authorization, quantity limit) that you or your prescriber believes should not apply. Once an exception is approved, it is approved for the remainder of the plan year. This means we cannot require a member to request approval for a refill or new prescription to continue using a Part D prescription drug already approved under the exceptions process, for the remainder of the plan year. In order to keep the exception in place for the whole year, the member must remain enrolled in Sharp Direct Advantage, the member’s physician or other prescriber must continue to prescribe the drug and the drug must continue to be safe for treating the member’s condition.

When an exception request is approved, we will give the member a written approval letter and clearly state the date that coverage will end.

Sharp Direct Advantage may immediately remove a brand name drug on our Drug List if we are replacing it with a newly approved generic version of the same drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a higher cost-sharing tier or add new restrictions. We may not tell you in advance before we make that change—even if you are currently taking the brand name drug.

Sharp Direct Advantage may make other changes once the year has started that affect drugs you are taking. For instance, we might add a generic drug that is not new to the market to replace a brand name drug or change the cost-sharing tier or add new restrictions to the brand name drug. We also might make changes based on FDA boxed warnings or new clinical guidelines recognized by Medicare. We will give written notice to affected enrollees at least 30 days in advance of the change becoming effective. If we are unable to give a 30-day advance notice, we will provide a 30-day supply of the drug impacted by the change and give written notice at the time of your refill.

Please contact us with any questions.


Download the Medicare Prescription Drug Coverage Determination Request Form (individual and group). You cannot use this form for Medicare non-covered drugs:

  • fertility drugs
  • drugs prescribed for weight loss, weight gain or hair growth
  • over-the-counter drugs
  • prescription vitamins (except prenatal vitamins and fluoride preparations)


Formulary exceptions

You, your prescriber, or your Authorized Representative may request a formulary exception by faxing or mailing a completed Medicare Prescription Drug Coverage Determination Form to us.

Sharp Direct Advantage uses various tools to ensure the quality of the health care it provides. These tools also extend to providing prescription drug coverage. These tools include, but are not limited to: prior authorization criteria, clinical edits and quantity limits.


Age limits

Age Limits: Some drugs require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.


Quantity limits

Quantity Limits: For certain drugs, Sharp Direct Advantage limits the amount of the drug we will cover per prescription or for a defined period of time.


Step therapy

In some cases, Sharp Direct Advantage requires you to first try one drug before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B. Here are details on the step therapy requirements for 2020.



Prior authorization

We require you to get prior authorization for certain drugs. You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, the drug may not be covered by Sharp Direct Advantage. View the prior authorization requirements for 2020.


Opioid Safety Program

Sharp Health Plan is required to comply with the Centers for Medicare & Medicaid Services requirements to prevent opioid overuse and protect patient safety. As a result, we have enhanced our opioid safety program to include various safety edits to prevent prescription opioid overuse in new opioid users, chronic opioid users, and those with potentially unsafe concurrent medication use. Below is an overview of our opioid safety edits for all Sharp Direct Advantage members.

Opioid cumulative dose safety edit (effective since 1/1/2020)

The opioid cumulative dose safety edit will trigger and deny the member’s prescription when the member’s cumulative morphine milligram equivalents (MME) per day across their opioid prescription(s) exceeds the safety threshold at the pharmacy. The edit will have the following features:

  1. Soft edit: For claims from four or more prescribers that meet or exceed 90 MME, pharmacies will be notified to verify dosing with the prescriber and to ensure care coordination. Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.
  2. Hard edit: For claims from four or more prescribers that meet or exceed 200 MME, pharmacies will be notified that a coverage determination is required. The prescriber will need to request a coverage determination to confirm dosing. Pharmacies are unable to use an override code.

Opioid and benzodiazepine concurrent use safety edit (effective 1/1/2020)

The opioid and benzodiazepine concurrent use safety edit will trigger and deny the member’s prescription when the member has any overlap in day supply for opioids and benzodiazepines at the pharmacy. The edit will have the following feature:

  1. Soft edit: Checks the member's prescription history for interactions between opioids and benzodiazepines. Pharmacies will be notified to verify with the prescriber the appropriateness of using both medications at the same time. Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.

Opioid naïve day supply limitation safety edit (effective 1/1/2020)

The opioid naïve day supply limitation safety edit will trigger and deny the member’s prescription when the member’s initial opioid prescription fill for the treatment of acute pain exceeds 7-day supply. Both short-acting and long-acting opioids, except buprenorphine for medication-assisted treatment (MAT) will be included in this safety edit. The edit will have the following feature:

  1. Hard edit: For patients without an opioid prescription filled in the last 108 days, claims for an opioid prescription will be limited to a 7-day supply for the treatment of acute pain. For claims exceeding a 7-day supply, pharmacies will be notified that a coverage determination is required. The prescriber will need to request a coverage determination to confirm dosing. Pharmacies are unable to use an override code.

Duplicative long-acting opioid therapy safety edit (effective 1/1/2020)

The duplicative long-acting opioid therapy safety edit will trigger and deny the member’s prescription when the member has any overlap in day supply for two or more long-acting opioid medications. The edit will have the following feature:

  1. Soft edit: If two or more prescriptions for long-acting opioids overlap in day supply, pharmacies will be notified to verify with the prescriber the appropriateness of using both medications at the same time. Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.

Opioid and buprenorphine concurrent use safety edit (effective 1/1/2020)

The opioid and buprenorphine concurrent use safety edit will deny the member’s opioid prescription claim at the pharmacy when the member is concurrently using any buprenorphine-containing product for medication assisted treatment (MAT).

  1. Soft edit: Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.

Members in long-term care facilities, with sickle cell disease, enrolled in hospice, in palliative care, or being treated for cancer will be exempted from opioid edits.

For all opioid safety edits, Sharp Health Plan will apply the appropriate drug utilization review process to ensure access is maintained for needed medications, and the dispensing pharmacist will be given the opportunity to override the rejection for soft edit.


Generic substitution

When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug. If the brand-name drug is approved, you may be responsible for a higher co-pay and/or the difference in cost between the brand and generic medications. Prior authorization criteria‚ clinical step edits and quantity limits may also apply.


Part D transition program information

Prescription drug transition process
What to do if your current prescription drugs are not on the formulary or are restricted in some way.

New members
As a new member of a Sharp Direct Advantage plan, insured through Sharp Health Plan, you may currently be taking drugs that are not on our formulary or are on our formulary but coverage is restricted in some way.

Under certain circumstances, you may be able to get a temporary supply of your prescription drug. This will give you and your doctor time to change to another drug or request an exception and ask to cover the drug or remove restrictions from the drug. If the exception is approved, you will be able to obtain the drug you are taking for the specified period of time.

While you are talking with your doctor to determine your course of action, you are eligible to receive an initial 30-day supply of the drug anytime during the first 90 days you are a member of our plan. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply. The prescription must be filled at a network pharmacy.

After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request an exception.

If you are a resident of a long-term care facility, we will cover a temporary supply of your drug during the first 90 days of your membership in our plan. The total supply will be for a maximum of a 34-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 34-day supply. Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.

If you reside in a long-term care facility and need a drug that is not on our formulary or coverage is restricted in some way, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for less than 31 days) while you pursue a formulary exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., in the week before a long-term care discharge) that occur after the first 90 days that you are enrolled as a member of our plan. If you are prescribed a drug that is not on our formulary or coverage is restricted in some way, you may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue an exception. This is in addition to the above long-term care transition supply.

Continuing members
As a continuing member in the plan, you receive an Annual Notice of Change (ANOC). We will tell you about any change in the coverage for your drug for next year.

If a drug you are taking will be removed from the formulary or restricted in some way for next year, work with your doctor to find a different drug that we cover. If there is no alternative, you or your doctor can request a formulary exception.

If you have not discussed with your doctor to switch to an alternative formulary medication or pursued a formulary exception, you are eligible to receive a temporary 30-day supply of your drug as of January 1 of the next benefit year. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply. The prescription must be filled at a network pharmacy. After your 30-day transition supply, we may not continue to pay for your drug under the transition policy. You are reminded to work with your doctor to find a different drug that we cover or you or your doctor can request an exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., in the week before a long-term care discharge) that can occur anytime. If you are prescribed a drug that is not on our formulary or coverage is restricted in some way, you are required to use the Plan's exception process. You may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you are a resident of a long-term care facility, we will cover up to a temporary 31-day supply (unless you have a prescription written for less than 31 days). If you have any questions about our transition policy or need help asking for a formulary exception, please contact Sharp Health Plan customer care.


Quality assurance policy and procedures

Sharp Health Plan’s Medicare Part D Quality Assurance policies are designed to ensure the safe and appropriate use of prescription drugs. Sharp Health Plan utilizes drug utilization review (DUR) systems and controls to improve the quality of care provided to our members by identifying patterns of inappropriate or medically unnecessary drug utilization. DUR controls are used to meet the following goals:

  • Reduce medication errors
  • Reduce adverse drug interactions
  • Improve medication use
  • Reduce costs when medically appropriate

Prescription drug claims processing, DUR control implementation, and pharmacy network management is performed by Sharp Health’s pharmacy benefit manager. The pharmacy benefit manager has the ability to control which messages are sent to the pharmacy and also to deny claims when a contraindication occurs.  

Several levels of concurrent DUR controls are used during the processing of prescription drug claims at the pharmacy. Level One and Level Two controls are safety controls and include but are not limited to the following:

  • Drug-drug interaction
  • High or low dosage
  • Ingredient duplication
  • Drug-age interaction
  • Pregnancy
  • Gender
  • Therapeutic duplication
  • Quantity limits
  • Late refill or underuse
  • Refill too soon or overuse

Sharp Health Plan also uses the following safety edits to ensure the safe and appropriate use of opioids:

  • Opioid prescriptions for greater than a 7-day supply in members new to opioid therapy
  • Care coordination safety edit for members receiving greater than 90 morphine milligram equivalent (MME) from 4 or more prescribers
  • Members received greater than 200 MME from 4 or more prescribers
  • Duplicative long-acting opioid therapy
  • Concurrent opioid and benzodiazepine therapy
  • Concurrent opioid and buprenorphine for medication assisted treatment (MAT) therapy

In addition to concurrent DUR controls, Sharp Health Plan performs retrospective DUR. Retrospective DUR activities include but are not limited to the following:

  • Medication Therapy Management Program
  • Review of CMS-generated reports (e.g. Outlier Prescribers of Scheduled II Controlled Substances, CMS/MEDIC Pharmacy Risk Assessment, CMS Quarterly Drug Trend Analysis, etc.)
  • Review of plan-generated reports to identify over- and under-utilization

For additional information regarding your plan benefits, please contact: Sharp Health Plan at 1-855-562-8853 (TTY/TDD:711).

Sharp Health Plan’s hours of operation are 8 am to 8 pm Pacific Time, Monday through Friday. From October through March, you can call us seven days a week. Calling after hours will direct you to our voicemail system and a Customer Care representative will return your call the next business day.



2019

  • Formulary 2019
  • Medication therapy management program 2019
  • Drug coverage determinations 2019
  • Exceptions, limitations and coverage determinations 2019
  • Part D transition program 2019
  • Quality assurance policy 2019
Formulary information

Sharp Direct Advantage provides Medicare prescription drug coverage under an approved formulary. The formulary or drug list is a list of covered drugs provided by Sharp Direct Advantage. The formulary drugs are selected because they are believed to be a necessary part of a quality treatment program.

Sharp Direct Advantage covers both brand name and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. The formulary is updated regularly. Please review your prescriptions to ensure they are covered.

You may view the formulary in the Drug List below. To search for a specific drug, press control “F” and enter the name of the drug, and press enter.

Formulary
Individual and group drug list – Sharp Direct Advantage comprehensive formulary
Individual and group drug list – Sharp Direct Advantage comprehensive formulary, in Spanish
Individual and group drug list – Sharp Direct Advantage formulary search tool


Search/view the 2019 drug list

How to use the online drug search tool

To search for a specific drug using the online search tool, type in the name of the drug in the search box. A drop-down list will appear with a list of drugs from which you can select the drug you are searching for. Once selected, click on the "Search" button and you will be redirected to a new page where you can click on the link for the drug and view its information.


How to use the PDF drug list

To search for a specific drug in the PDF, press control (CTRL) and "F" on your keyboard. A search box will appear in the top right corner of your browser where you can enter in the name of the drug you are looking for.


Search online drug list  View drug list (PDF)  View drug list in Spanish (PDF)


What is the medication therapy management program

The Medication Therapy Management Program (MTMP) is provided by Sharp Direct Advantage to make sure that members are using the drugs that work best in treating their medical conditions. As part of the MTMP, qualified members receive a one-on-one medication review with a pharmacist or licensed pharmacy intern under the direct supervision of a pharmacist followed by targeted medication reviews on a quarterly basis. The program is offered to you at no extra cost. This MTMP is not considered a benefit.


How you qualify for the program

Sharp Health Care determines, by looking at your monthly medication claims information, if you are eligible for the program. To qualify for the MTMP, you must meet all three of the following criteria:

 

  1. Have two of the six following conditions:
    • Chronic Heart Failure (CHF)
    • Diabetes
    • Dyslipidemia (abnormal cholesterol)
    • Hypertension
    • Asthma
    • Chronic Obstructive Pulmonary Disease (COPD)
  2. And are taking seven or more chronic (Part D) drugs in a 30-day period,
  3. And are likely to pay annual Part D medication costs of $4,044.


How you are notified of your MTMP eligibility

Once eligible, you will receive a letter of your eligibility that invites you to make a telephone appointment to have a one-on-one medication review. Your letter will give you an explanation of the program, and gives you instructions if you want to opt-out of the program.

You may request a medication review by returning the appointment form enclosed with the letter or calling the toll free number in the letter. You may also contact us for assistance.


How MTMP works

As part of your medication review, (which takes around 15 to 30 minutes), you will:

  • Go over by phone the medicines you are currently taking with the pharmacist or the licensed pharmacy intern under the supervision of a pharmacist
  • Make sure with the pharmacist or the licensed pharmacy intern under the supervision of a pharmacist that your medicines are safe for you
  • Ask any questions you may have about your medicines
  • Discuss lower-cost alternatives for your medicines
  • Discuss any concerns you have about your medicines
  • Learn ways to keep track of your medicines
  • Receive a summary of your medication review that includes the Personal Medication List and a Medication Action Plan. You can take these to your doctor for further medication management.
  • Have your medications reviewed quarterly.

For your convenience, a blank medication list may be printed by clicking the link below. Please use the form to keep track of all your prescriptions and over-the-counter medications.

Blank medication list form


Call with questions

To learn more or get additional information, please contact us.


Exceptions & prior authorization

Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing doctor’s supporting statement. You can request an expedited (fast) request 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 your prescriber’s or prescribing doctor’s supporting statement.

Exceptions are also called coverage determinations. Members can request an exception to the Sharp Direct Advantage cost-sharing structure, to the formulary, or to obtain a formulary drug that is subject to a utilization management restriction (e.g., step therapy, prior authorization, quantity limit) that you or your prescriber believes should not apply. Once an exception is approved, it is approved for the remainder of the plan year. This means we cannot require a member to request approval for a refill or new prescription to continue using a Part D prescription drug already approved under the exceptions process, for the remainder of the plan year. In order to keep the exception in place for the whole year, the member must remain enrolled in Sharp Direct Advantage, the member’s physician or other prescriber must continue to prescribe the drug and the drug must continue to be safe for treating the member’s condition.

When an exception request is approved, we will give the member a written approval letter and clearly state the date that coverage will end.

Should Sharp Direct Advantage change the formulary or the cost-sharing status of a drug during the plan year, we will give written notice to affected enrollees at least 30 days in advance of the change becoming effective. If we are unable to give a 30-day advance notice, we will provide a 30-day supply of the drug impacted by the change and give written notice at the time of your refill.

Please contact us with any questions.

See below for the Medicare Prescription Drug Coverage Determination Request Form. You cannot use this form for Medicare non-covered drugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).

Individual and group - Medicare Prescription Drug Coverage Determination Request Form


Formulary exceptions

You, your prescriber, or your Authorized Representative may request a formulary exception by faxing or mailing a completed Medicare Prescription Drug Coverage Determination Form to us.

Individual and group - Medicare Prescription Drug Coverage Determination Form
 
You can also fill out a Medicare Prescription Drug Coverage Determination Form online.

Sharp Direct Advantage uses various tools to ensure the quality of the health care it provides. These tools also extend to providing prescription drug coverage. These tools include‚ but are not limited to: prior authorization criteria‚ clinical edits and quantity limits.


Age limits

Age Limits: Some drugs require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.


Quantity limits

Quantity Limits: For certain drugs, Sharp Direct Advantage limits the amount of the drug we will cover per prescription or for a defined period of time.


Step therapy

In some cases, Sharp Direct Advantage requires you to first try one drug before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B. Here are details of the 2019 step therapy requirements.



Prior authorization

We require you to get prior authorization for certain drugs. You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, the drug may not be covered by Sharp Direct Advantage. View the 2019 prior authorization requirements.


Opioid Safety Program

Sharp Health Plan is required to comply with the Centers for Medicare & Medicaid Services requirements to prevent opioid overuse and protect patient safety. As a result, we have enhanced our opioid safety program to include various safety edits to prevent prescription opioid overuse in new opioid users, chronic opioid users, and those with potentially unsafe concurrent medication use. Below is an overview of our opioid safety edits for all Sharp Direct Advantage members.

Opioid Cumulative Dose Safety Edit (effective since 1/1/2017)

The Opioid Cumulative Dose Safety Edit will trigger and deny the member’s prescription when the member’s cumulative morphine milligram equivalents (MME) per day across their opioid prescription(s) exceeds the safety threshold at the pharmacy. The edit will have the following features:

  1. Soft Edit - For claims from 2 or more prescribers that meet or exceed 90 MME, pharmacies will be notified to verify dosing with the provider. Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.
  2. Hard Edit - For claims from 2 or more prescribers that meet or exceed 200 MME, pharmacies will be notified that a coverage determination is required. The provider will need to request a coverage determination to confirm dosing. Pharmacies are unable to use an override code.

Opioid and Benzodiazepine Concurrent Use Safety Edit (effective 1/1/2019)

The Opioid and Benzodiazepine Concurrent Use Safety Edit will trigger and deny the member’s prescription when the member has any overlap in day supply for opioids and benzodiazepines at the pharmacy. The edit will have the following feature:

  1. Soft Edit - For claims from 2 or more prescribers of Part D opioid drugs that overlap with Part D benzodiazepine drugs, pharmacies will be notified to verify the appropriateness of using both medications at the same time with the provider. Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.

Opioid Naïve Day Supply Limitation Safety Edit (effective 1/1/2019)

The Opioid Naïve Day Supply Limitation Safety Edit will trigger and deny the member’s prescription when the member’s initial opioid prescription fill for the treatment of acute pain exceeds 7 days supply.   Both short-acting and long-acting opioids, except buprenorphine for medication-assisted treatment (MAT) will be included in this safety edit. The edit will have the following feature:

  1. Hard Edit - For patients without an opioid prescription filled in the last 60 days, claims for an opioid prescription will be limited to a 7 day supply for the treatment of acute pain. For claims exceeding 7 days supply, pharmacies will be notified that a coverage determination is required. The provider will need to request a coverage determination to confirm dosing. Pharmacies are unable to use an override code.

Duplicative Long-Acting Opioid Therapy Safety Edit (effective 1/1/2019)

The Duplicative Long-Acting Opioid Therapy Safety Edit will trigger and deny the member’s prescription when the member has any overlap in day supply for multiple long-acting opioid medications.  The edit will have the following feature:

  1. Soft Edit - For claims from 2 or more prescribers that meet or exceed 2 prescriptions for Long-Acting Opioids that overlap in day supply, pharmacies will be notified to verify the appropriateness of using both medications at the same time with the provider. Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.

Opioid and Buprenorphine Concurrent Use Safety Edit (effective 1/1/2019)

This will deny the member’s opioid prescription claim at the pharmacy when the member is concurrently using any buprenorphine-containing product for medication assisted treatment (MAT).

  1. Hard Edit - The provider will need to request a coverage determination to confirm dosing. Pharmacies are unable to use an override code.

Members in long-term care facilities, with sickle cell disease, enrolled in hospice, in palliative care or being treated for cancer will be exempted from opioid edits.

For all opioid safety edits, Sharp Health Plan will apply the appropriate drug utilization review process to ensure access is maintained for needed medications, and the dispensing pharmacist will be given the opportunity to override the rejection for soft edit.


Generic substitution

When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug. If the brand-name drug is approved, you may be responsible for a higher co-pay and/or the difference in cost between the brand and generic medications. Prior authorization criteria‚ clinical step edits and quantity limits may also apply.


Part D transition program information

Prescription drug transition process
What to do if your current prescription drugs are not on the formulary or are restricted in some way.

New members
As a new member of a Sharp Direct Advantage plan, insured through Sharp Health Plan, you may currently be taking drugs that are not on our formulary or are on our formulary but coverage is restricted in some way.

Under certain circumstances, you may be able to get a temporary supply of your prescription drug. This will give you and your doctor time to change to another drug or request an exception and ask to cover the drug or remove restrictions from the drug. If the exception is approved, you will be able to obtain the drug you are taking for the specified period of time.

While you are talking with your doctor to determine your course of action, you are eligible to receive an initial 30-day supply of the drug anytime during the first 90 days you are a member of our plan. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply. The prescription must be filled at a network pharmacy.

After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request an exception.

If you are a resident of a long-term care facility, we will cover a temporary supply of your drug during the first 90 days of your membership in our plan. The total supply will be for a maximum of a 34-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 34-day supply. Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.

If you reside in a long-term care facility and need a drug that is not on our formulary or coverage is restricted in some way, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for less than 31 days) while you pursue a formulary exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., in the week before a long-term care discharge) that occur after the first 90 days that you are enrolled as a member of our plan. If you are prescribed a drug that is not on our formulary or coverage is restricted in some way, you may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue an exception. This is in addition to the above long-term care transition supply.

Continuing members
As a continuing member in the plan, you receive an Annual Notice of Change (ANOC). We will tell you about any change in the coverage for your drug for next year.

If a drug you are taking will be removed from the formulary or restricted in some way for next year, work with your doctor to find a different drug that we cover. If there is no alternative, you or your doctor can request a formulary exception. We will allow you to request a formulary exception in advance for next year. You may request a formulary exception starting October 15th and we will give you an answer within 72 hours after we receive your request (or your prescriber's supporting statement). If your request is approved, we will cover the drug as of January 1 of the following year for the specified period of time.

If you have not discussed with your doctor to switch to an alternative formulary medication or pursued a formulary exception, you are eligible to receive a temporary 30-day supply of your drug as of January 1 of the next benefit year. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply. The prescription must be filled at a network pharmacy. After your 30-day transition supply, we may not continue to pay for your drug under the transition policy. You are reminded to work with your doctor to find a different drug that we cover or you or your doctor can request an exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., in the week before a long-term care discharge) that can occur anytime. If you are prescribed a drug that is not on our formulary or coverage is restricted in some way, you are required to use the Plan's exception process. You may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you are a resident of a long-term care facility, we will cover up to a temporary 31-day supply (unless you have a prescription written for less than 31 days). If you have any questions about our transition policy or need help asking for a formulary exception, please contact Sharp Health Plan customer care.


Quality assurance policy and procedures

Sharp Health Plan’s Medicare Part D Quality Assurance policies are designed to ensure the safe and appropriate use of prescription drugs. Sharp Health Plan utilizes drug utilization review (DUR) systems and controls to improve the quality of care provided to our members by identifying patterns of inappropriate or medically unnecessary drug utilization. DUR controls are used to meet the following goals:

  • Reduce medication errors
  • Reduce adverse drug interactions
  • Improve medication use
  • Reduce costs when medically appropriate

Prescription drug claims processing, DUR control implementation, and pharmacy network management is performed by Sharp Health’s pharmacy benefit manager. The pharmacy benefit manager has the ability to control which messages are sent to the pharmacy and also to deny claims when a contraindication occurs.  

Several levels of concurrent DUR controls are used during the processing of prescription drug claims at the pharmacy. Level One and Level Two controls are safety controls and include but are not limited to the following:

  • Drug-drug interaction
  • High or low dosage
  • Ingredient duplication
  • Drug-age interaction
  • Pregnancy
  • Gender
  • Therapeutic duplication
  • Quantity limits
  • Late refill or underuse
  • Refill too soon or overuse

Sharp Health Plan also uses the following safety edits to ensure the safe and appropriate use of opioids:

  • Opioid prescriptions for greater than a 7-day supply in members new to opioid therapy
  • Care coordination safety edit for members receiving greater than 90 morphine milligram equivalent (MME) from 2 or more prescribers
  • Members received greater than 200 MME from 2 or more prescribers
  • Duplicative long-acting opioid therapy
  • Concurrent opioid and benzodiazepine therapy
  • Concurrent opioid and buprenorphine for medication assisted treatment (MAT) therapy

In addition to concurrent DUR controls, Sharp Health Plan performs retrospective DUR. Retrospective DUR activities include but are not limited to the following:

  • Medication Therapy Management Program
  • Review of CMS-generated reports (e.g. Outlier Prescribers of Scheduled II Controlled Substances, CMS/MEDIC Pharmacy Risk Assessment, CMS Quarterly Drug Trend Analysis, etc.)
  • Review of plan-generated reports to identify over- and under-utilization

For additional information regarding your plan benefits, please contact: Sharp Health Plan at 1-855-562-8853 (TTY/TDD:711).

Sharp Health Plan’s hours of operation are 8 am to 8 pm Pacific Time, Monday through Friday. From October through March, you can call us seven days a week. Calling after hours will direct you to our voicemail system and a Customer Care representative will return your call the next business day.


 

Sharp Direct Advantage is offered by Sharp Health Plan. Sharp Health Plan is an HMO with a Medicare contract. Enrollment with Sharp Health Plan depends on contract renewal. Read the full disclaimer.

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