Note: Some employers receive their pharmacy benefit from another vendor. If a member’s identification card does not have pharmacy benefit information printed in the lower left hand corner, MHP does not provide pharmacy benefits for that member.
MHP maintains Commercial formularies and Medicare Advantage (Part D) formularies for outpatient prescription drugs. The formularies list the medications covered under MHP’s prescription drug benefit, including the medication’s applicable co-pay tier and any prior authorization, quantity limitations or step therapy requirements. Formularies are developed and maintained by MHP’s Formulary Management Committee comprised of practicing physicians and pharmacists.
In order to keep formularies current, the Formulary Management Committee meets regularly to review:
Medical and clinical literature including clinical trials;
Relevant patient utilization and experience;
Current therapeutic guidelines;
Economic data;
Provider recommendations; and
The safest, most effective drugs that will produce the desired goals of therapy at the most reasonable cost to the healthcare system.
Please consider prescribing medications from the applicable Commercial or Medicare Advantage formularies that have the lowest co-pay tiers, such as generics, when clinically appropriate. Lower co-pay tiers are associated with lower member cost-share.
MHP formularies are available at mercyhealthplans.com or through your provider relations representative.
Drugs that are newly made available to the marketplace are not covered under the Commercial pharmacy benefit until they have been reviewed by MHP’s Formulary Management Committee for appropriate formulary placement. New-to-market drug reviews occur approximately six months after a drug has entered the marketplace. This time frame allows for the collection of comprehensive clinical and economic data, identification of how the drug is being used in the marketplace along with its efficacy, and identification of any unforeseen adverse events not identified in clinical trials. If you determine that a new-to-market drug is the most clinically appropriate medication for your patient prior to formulary placement, you may request coverage of the drug by contacting MHP’s Prior Authorization Department as outlined in the prior authorization section, below.
MHP’s pharmacy benefit design encourages the use of effective, less costly generic medications. Generic medications have a lower member cost-share. Most generics are assigned a Maximum Allowable Cost (MAC) limit of reimbursement. If a physician indicates 'Dispense as Written' or if a member chooses to get the brand-name for a medication that is available generically and on the MAC list, the member may incur the generic co-pay plus the cost difference between the brand-name medication and the MAC price.
Self-administered injectables are covered under the pharmacy benefit. Many self-administered injectables are high-cost medications used to treat rare, chronic conditions and require special handling. Most are covered at the highest member cost-share, require prior authorization and are subject to quantity limits of up to a 30-day supply per fill.
A small number of employers receive their pharmacy benefit through another vendor. For these groups, self-administered injectables will be covered by the appropriate pharmacy benefit vendor and not by MHP.
Formulary drugs with a high potential for misuse, limited therapeutic indications, maximum dosing recommendations based on safety concerns, or those drugs requiring extensive monitoring for side effects may require prior authorization. In addition, prior authorization is used as a means to identify members who may benefit from additional services such as case management or disease management.
Prior authorization criteria are established by MHP’s Formulary Management Committee and are based on FDA-approved drug labeling and evidence-based medical standards. Medications requiring prior authorization are designated in the formulary listing by a 'PA.' A list of medications requiring prior authorization is available at mercyhealthplans.com.
For a member to receive coverage for a medication requiring prior authorization, the physician can call MHP’s Prior Authorization Department at 314-214-8282 or 800-647-2240. In addition, requests can be faxed to MHP’s Prior Authorization Department at 314-214-8201 or 800-466-9854 on a drug-specific Prior Authorization Request form or on a Medical Exception Request Form. These fax forms can be found under 'Forms' in the Provider section of mercyhealthplans.com.
Certain medications are subject to quantity limits. Medications with quantity limits are designated in the formulary listing by an 'MDL.' MHP uses medical guidelines and FDA-approved recommendations from drug makers to set these coverage limits. The quantity limit program includes:
Dose Efficiency Edits - Examples include limiting coverage of prescriptions to one dose per day for drugs that are approved for once-daily dosing and limiting coverage of two capsules/tablets per day when one capsule/tablet of equal strength is clinically equivalent;
Maximum Daily Dose - Limits coverage of quantities that exceed recommended maximum dosage amounts; and
Quantity Limits Over Time - Limits coverage of prescriptions to a specific number of units in a defined amount of time.
To request prescription coverage for amounts that are over the allowed quantity, you may request a medical exception by contacting MHP’s Prior Authorization Department as outlined in the Prior Authorization section above.
Certain medications are subject to step therapy. Medications with step therapy requirements are designated in the formulary listing by an 'ST.' A step-therapy approach to care requires the use of a recognized first-line drug before approval of a second-line drug is given. Step therapies are a safe and effective method to reduce the cost of treatment by ensuring that a proven and cost-effective therapy is tried before progressing to more costly remedies. If you determine that the required therapeutic benefit will not be achieved by use of a first-line drug, the prescriber may request use of a second-line medication by contacting the MHP Prior Authorization Department as outlined above.
Certain medications are not on the formulary and are considered non-covered. MHP’s Formulary Management Committee has deemed them non-covered because they are either categorized as a benefit exclusion or they offer no clinical, safety, or economic advantage over formulary options. Examples of medications that are benefit exclusions include: weight management drugs, drugs that can be obtained over-the-counter (OTC), drugs for cosmetic use, experimental and investigational uses of drugs, drugs classified as medical foods, and drugs for infertility (unless mandated by state regulations or covered under a separate infertility rider). In addition, The Medicare Modernization Act of 1996 specifically prohibits certain medications from being covered under Medicare Part D; therefore, the following types of drugs are specifically excluded from coverage for our Medicare Advantage members:
Drugs used for anorexia, weight loss, or weight gain;
Drugs used to promote fertility;
Drugs used for cosmetic purposes or hair growth;
Drugs used for the symptomatic relief of cough and colds;
Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations;
Non-prescription (over-the-counter) drugs;
Inpatient drugs;
Barbiturates; and
Benzodiazepines.
For non-covered medications that are NOT categorized as a benefit exclusion, you may request coverage of the non-covered/non-formulary drug by contacting the MHP Prior Authorization Department as outlined in the Prior Authorization section above.
MHP members can obtain their prescriptions from a national network of contracted pharmacy providers. A comprehensive list of pharmacy providers is available through MHP’s online provider directory at mercyhealthplans.com.
MHP employs several drug utilization programs with a focus on patient safety and appropriate member use of controlled substances. These programs consist of a retrospective review of prescription drug claims to identify opportunities to maximize drug therapy or to address inappropriate use of controlled substances at the member level. Examples of patient safety opportunities include: therapeutic duplication where the member is receiving medications from the same therapeutic class (e.g., ACE-inhibitors) from two different prescribers, drug/disease contraindications, and drug/age safety concerns.
You may receive written notification from us alerting you to drug regimen problems identified in our DUR programs. The notification includes a summary of the potential problem identified along with a patient prescription history that lists all medications prescribed for the patient by all prescribers. We hope you find this information helpful in optimizing your patients’ drug regimens.
When we make formulary changes that result in a drug moving to a higher co-pay tier or no longer being covered, you will receive notification from us at least 30 days in advance if you have any impacted patients. In addition, we notify impacted members encouraging them to proactively speak to their physician about the coverage change and the possibility of switching to a covered formulary alternative, if appropriate. This does not apply to drugs removed from the market by the FDA or due to a drug recall.
MHP covers routine patient care costs associated with cancer clinical trials. It does not cover the costs of the experimental/investigational drug(s). If you have a patient that you intend to participate in a clinical trial, please notify MHP’s Prior Authorization Department for approval prior to enrolling the member in the trial or providing services related to the clinical trial. The Prior Authorization Department can be notified by calling MHP’s Prior Authorization line at 314-214-8282 or 800-647-2240 and choosing the option to speak to a medication specialist. In addition, requests can be faxed to MHP’s Prior Authorization Department at 314-214-8201 or 800-466-9854 on a Medical Exception Request Form found under ”r;Forms” in the Provider section of mercyhealthplans.com.
MHP provides a reconsideration (peer-to-peer) and an appeal process for members and providers in the event of an Adverse Determination. An adverse determination is a decision by MHP or its designee, whereby a request for coverage of a non-covered medication or a medication subject to prior authorization, quantity limits, or step therapy requirements has been reviewed and, based upon the information provided, does not meet MHP’s requirements for coverage. As a result, the coverage for the requested service is subsequently denied.
MHP adheres to the following timeframes when making a determination:
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Requests for urgent conditions |
The medical director will issue a decision within one calendar day of the peer-to-peer opportunity (and receiving complete clinical information to adequately demonstrate the necessity of the treatment.) |
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Requests for non-urgent conditions |
The medical director will issue a decision within three calendar days (72 hours) of the peer-to-peer opportunity (and receiving complete clinical information to adequately demonstrate the necessity of the treatment.) |
Adverse determinations made in the course of the review process are communicated verbally to the provider within one day from when the determination was made. This communication is confirmed within three business days by written notice of the determination and any coinciding recommendations. This letter is mailed to the member or responsible party and the physician. The reasons for the adverse determination, available alternatives and the appeal rights and procedures are included in the notices of denial, along with a contact person’s name and phone number.
If the reconsideration process does not resolve the difference of opinion, the Adverse Determination may be appealed by the provider (on behalf of the member). The member may also utilize the Grievance/Appeals Processes identified in Chapter 8. Any member or provider may appeal directly to the MHP’s Appeals Coordinator at:
Mercy Health Plans
ATTN: Corporate Appeals
14528 South Outer Forty Road, Suite 300
Chesterfield, MO 63017-5743