Highlights

It’s a commoditized category that’s highly genericized. So, you have to step through the generics before you can go onto the brands. Now, at least in our program we don’t have any time limit on it, we just have to have tried the generics and it didn’t work, or there was a problem, or a side effect and then you’d go onto the new agents/brands. All these drugs are prior authorized with regards to the label, to quantity limits, and we require the use of our mail order pharmacy, as a national payer we have our own PBM and pharmacy, and specialty pharmacy that we supply the drugs, even in the uninjectable side, we will send it out. Occasionally we’ll allow buy and bill if we need the provider and the network, but we don’t pay any more than we pay ourselves.

The physician is entitled to what’s called a peer-to-peer call if there’s some compelling medical reason that they need to stay on whatever they’re on, or there’d be some medical contraindications of them switching, but otherwise we consider these fairly interchangeable in the category, but there is the option for that, and there’s always the option no one loses their appeal rights, so that even if we deny it as non-formulary and by the way, and I always council the physician that if there is a medical reason to do an override to the brand, and bypass the generic it’s going to cost the member more, so, they have to take that into consideration.