Restrictions to Our Covered Drugs
For certain prescription drugs, Community CCRxSM has additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for Community CCRx to help us to provide quality care to our members.
Examples of utilization management tools include:
Prior Authorization: Community CCRx requires you to get prior authorization for certain drugs. This means that you will need to get approval from Community CCRx before you fill your prescription. If you do not get approval, Community CCRx may not cover the drug.
Quantity Limits: For certain drugs, Community CCRx limits the amount of the drug that we will cover per prescription or for a defined period of time. For example, Community CCRx will provide up to 10 capsules per prescription of TAMIFLU.
Step Therapy: In some cases, Community CCRx requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Community CCRx may require your doctor to prescribe Drug A first. If Drug A does not work for you, only then will Community CCRx cover Drug B.
Generic Substitution: When there is a generic version of a brand-name drug available, Community CCRx network pharmacies will typically give you the equivalent generic version to save you expense unless your doctor has told us that you must take the brand-name drug.
Therapeutic Substitution: When there is a therapeutic alternative to treat your condition, your pharmacist or Community CCRx. Plan may contact your doctor to see if the alternative drug is appropriate for you. Only your doctor can authorize this change.
Learning if your drug has restrictions
You can find out if your drug is subject to these additional requirements or limits by searching the formulary. If your drug does have these additional restrictions or limits, you can ask Community CCRx to make an exception to our coverage rules.