Benefits Plans - Prescription Drug Plan: Coverage

• Prescription Drugs
• Additional Coverage
• Supply Limits
• Refill Too Soon
• Quantity Limits
• Dose Optimization Program
• Exclusions
• Prior Authorization Drugs
• Step Therapy
• Specialty Drugs
• Diabetic Injectable Insulin, Needles, and Syringes
• Diabetic Supplies and Equipment

Prescription Drugs

The University of Michigan Prescription Drug Plan covers outpatient, self-administered medications that require a written prescription. "Prescription" refers to an order written by any licensed physician, or others licensed to prescribe (e.g., dentists) for a medicinal substance which, under the Federal Food, Drug, and Cosmetic Act (FD&C Act), is required to bear on the packaging label the following legend: “Caution: Federal Law prohibits dispensing without a prescription,” or “Rx Only.”

The Prescription Drug Plan includes:

• All legend drugs, unless specified otherwise.
• Drug Efficacy Study Implementation Program (DESI) drugs as determined by the U.S. Food and Drug Administration (FDA) as lacking substantial evidence of effectiveness. The DESI drugs do not have studies to back up the medications' uses, but since they have been used and accepted for many years without significant safety problems, they continue to be used in today's marketplace. Examples of covered DESI drugs include Donnatal, Librax, and Tigan suppositories.
• Compounded medications are covered if all of the following criteria are met:
  A. The product contains at least two covered ingredients, at least one being an active prescription ingredient, and
  B. The prescription active ingredient(s) is FDA-approved for medicinal use in the United States, and
  C. The final route does not require administration by a health care professional, and
  D. The compounded product is not a copy of a commercially available FDA-approved drug product, and
  E. The safety and effectiveness of use for the prescribed indication is supported by FDA-approval or adequate medical and scientific evidence in the medical literature.
  
  Please note, compounded medications cannot be filled at NoviXus mail service.

FDA approval of a drug does not guarantee coverage by the plan. New drugs are subject to review by the university and MedImpact before being covered or excluded.

For coverage information on a specific medication, find a drug on the “formulary” at benefits.umich.edu/plans/drugs/formulary.html. Members can also use the “Drug Price Check” feature on the MedImpact member website https://mp.medimpact.com/umh. Drug lists are subject to change.

Additional Coverage

The plan also includes coverage for emergency allergic reaction kits and birth control medications, including oral and emergency contraceptives. Sterile Water is covered only for self-administered injection, not for irrigation. Certain medications and drugs are limited, excluded or require prior authorization from the plan.

Supply Limits

The University of Michigan prescription drug plan allows members to purchase up to 90-day supplies of each medication from a retail pharmacy or NoviXus mail service. Members on a tier co-pay plan may order 90-day supplies through the mail service for two co-pays, a 33% savings over retail.

Certain medications are considered Specialty Drugs, and with the exception of immunosuppressives, are limited to 34-day supplies, and cannot be ordered through NoviXus mail service. For more information, please visit the section on “Specialty Drugs”. Drug plan members have the following options for filling prescriptions at pharmacies in the MedImpact network:

• One-month supply (up to 34 days) for one (1) co-pay (retail pharmacy)
• Two-month supply (35 to 60 days) for two (2) co-pays (retail pharmacy)
• Three-month supply (61 to 90 days) for three (3) co-pays (retail pharmacy)
•  Up to 90-day supply for two (2) co-pays at NoviXus mail service

To have a 90-day supply dispensed, your physician must write your prescription for 90-day quantities. Please discuss this with your physician at your next regularly scheduled appointment.

Refill Too Soon

Prescriptions cannot be refilled before 75% use (26 days for a 34-day supply or 68 days for a 90-day supply). Certain drugs subject to quantity limits can be refilled no earlier than 25 days after a one-month supply or 75 days after a three-month supply. See section on “Quantity Limits” for more information.

Quantity Limits (QL)

Some drugs are subject to quantity limits (QL) on the amount of the medication that you can receive (number of days’ supply, quantity limits, frequency of refills, etc.). If your prescription exceeds the quantity limits, your physician may contact MedImpact to discuss additional supplies by calling 1-800-681-9578.

• Fertility agents (oral and injectable medications) are covered up to a lifetime family maximum of $5,000. In addition, prior authorization (PA) is required for participants age 45 and older. More information.
• One month extra refill of your prescriptions for vacations or travel overseas can be requested by contacting MedImpact at 1-800-681-9578. A maximum of two vacation overrides per medication are allowed each year.

Dose Optimization Program

The University of Michigan maintains within its Prescription Drug Plan a dose optimization or dose consolidation program for selected medications. The purpose of the program is to change multiple dose medications to a single daily dose where appropriate. The program applies when all of these criteria are met:

• The patient is taking an established medication for a chronic condition
• The medication is available in multiple strengths
• There is an opportunity for a member to change from multiple units per day dosing to a once daily dose of the same medication
• The physician supports the drug interchange as clinically appropriate for the patient
• Significant pharmacy cost savings can be achieved by the Prescription Drug Plan

MedImpact will notify a retail and/or mail-order pharmacist when there appears to be an opportunity for dose optimization. The pharmacist may contact the prescribing physician for approval of the dosage conversion.

Exclusions

Certain drugs and supplies are excluded from the plan. The exclusions listed below apply to both the retail and mail service program.

• Topical acne medications for individuals age 40 and older
• Some anorexiants, CNS stimulants (such as Adipex-P, Bontril)
• Blood products
• Cosmetic products, or any drug used for cosmetic purposes (such as Rogaine, Renova, Propecia, Avage, Tazorac, Botox, Latisse)
• Experimental, investigational or unproven drugs, or one that is being used for an indication that has not been approved by the FDA
• Injectable medications, except those listed in this website as covered, injections that must be administered by a health care professional are not covered.
• In general, new drugs and medicines that have not been reviewed by the plan
• Prescription products that offer no additional clinical benefit over existing available therapies or existing therapeutically equivalent products in the drug class. Examples include Staxyn, Edarbi)
• Prescription products that are the main active metabolite, the isolated enantiomer, prodrug, or an alteration of an existing product where no added clinical benefits have been shown by published, scientific, peer-reviewed, head-to-head comparative studies. Examples include Toviaz, Dexilant.
• Most over-the-counter (OTC) medications, any prescription medication that contains the same active ingredient(s) as an existing OTC medication, or kits that are packaged with an OTC medication. Examples include Lac-Hydrin, Mentax, Zaditor, MiraLAX, Lovaza, benzoyl peroxide products, Vimovo, and Xolegel Carepak Kit. More examples (PDF)
• Medical foods, examples include Limbrel, Deplin, FolTx, Metanx, Folbee Plus Cz, Diatx Zn, Cerefolin, Neevo and Neevo DHA, and Vanchol
• Vitamins, other than prenatal vitamins and injectable B-12, D and K (potassium)
• Therapeutic devices, appliances or medical equipment, support garments, or ostomy supplies.

Your U-M health plan benefits may cover certain medical equipment and supplies and/or injectables administered by your health care provider. Questions about items covered or excluded by your health plan should be directed to your health plan company.

Prior Authorization (PA) Drugs

Certain drugs require prior authorization from the plan. If your doctor prescribes any medication listed with a “PA” requirement, your doctor must contact MedImpact by calling 1-800-681-9578 to receive prior authorization before you fill your prescription. In some cases you may be required to submit a letter from your doctor verifying the medical necessity of the prescribed drug.

After the initial approval, prior authorization may be required again periodically.

For more information about the Prior Authorization process, see PA Appeals Process.

To check the status of your drug plan Prior Authorization(s), log on the MedImpact website for U-M members at https://mp.medimpact.com/umh

Step Therapy

The plan may select a number of specific drug categories in which drugs will be covered in a progression. Selected drug classes are reviewed and based on medical evidence and cost. Physicians must verify the patient’s trial and failure with a particular drug in the therapeutic class before permitted coverage for another drug (step drug progression) or provide medical documentation that the patient should be dispensed a drug out of sequence.

Specialty Drugs

A “specialty drug” is a prescription drug that is either a self-administered injectable medication; a medication that requires special handling, special administration, or monitoring; or is a high-cost oral medication. The Specialty Drug List includes select medications used to treat a variety of clinical conditions. The list is subject to change by the U-M Prescription Drug Plan.

Specialty drugs may be dispensed in quantities up to a 34-day supply. Prescriptions for specialty medications in the immunosuppressive category may be dispensed in quantities up to a 90-day supply.
Drugs on the U-M Prescription Drug Plan Specialty Drug List will only be covered at a designated specialty drug pharmacy. Please refer to the table below for information on the appropriate pharmacy for your specialty medication.

• Click here to download a list of Specialty Drugs (PDF)
• Click here for specialty drug pharmacy contact information
• FAQ

Diabetic Injectable Insulin, Needles and Syringes

Diabetic injectable insulin, needles and syringes are available to all participants in the University of Michigan prescription drug plan at a zero ($0) co-pay when the U-M MedImpact prescription drug ID card is used at a network retail pharmacy, or from NoviXus mail service.

Diabetic Supplies and Equipment

Coverage of diabetic supplies (injection devices, alcohol swabs, testing strips, lancets, and blood glucose testing monitors) is determined by your health plan participation as described below.

Participants in University of Michigan health plans (U-M Premier Care, Health Alliance Plan, or Blue Cross Blue Shield of Michigan) can receive diabetic supplies at zero ($0) co-pay only when the health plan ID card is used at an authorized provider. Contact your health plan administrator for further instructions on how to obtain diabetic supplies or reimbursement through your health plan.