Provider Manual—Commercial Plans

Pharmacy

Updates:  Revised November 2018

Quick links:

  1. Drug Lists
  2. Drug Preauthorization and Step Therapy Protocols
  3. Drug Limitations
  4. Specialty Drugs
  5. Nonformulary Requests



In health plans that include a prescription drug benefit, a comprehensive pharmacy services program is provided that includes drug list management, drug preauthorization, step therapy protocols, drug limitations, and a specialty drug program. 


1 Drug Lists

PacificSource Health Plans uses two base drug lists for their commercial line of business: a state based list (OR, MT, ID) to meet individual state exchange requirements, and our preferred drug list (PDL) which is an open option for large employer groups. Medicaid and Medicare lines of business each have their own drug list and website. Add-on lists are available, including an incentive list and preventive drug list (starting in 2015), which include no co-pay drugs for chronic conditions.

To find out which drug list applies to your patient’s pharmacy plan, check their PacificSource member ID card in the lower right corner. If no “Drug List” is noted on their card, use the “PDL” list. Please use the drug lists to prescribe the most clinically appropriate and cost-effective medications for your patient. Generics are generally available for the lowest cost. Preferred brands are available at a higher cost with nonpreferred brands available for the highest cost. Our drug lists are available online at PacificSource.com/drug-list.



2 Drug Preauthorization and Step Therapy Protocols

Certain drugs require preauthorization or step therapy for members with pharmacy or major medical prescription plans. This process includes an assessment of both your patient’s available benefits and medical indications for use. Be sure to preauthorize medication when required, to avoid your patient becoming responsible for the full cost of the medication.

We base our preauthorization and step therapy criteria on current medical evidence. We review and update them monthly to accommodate new drugs and changing recommendations. Our Quality Assurance, Utilization Management, Pharmacy and Therapeutics (QAUMPT) Committee must approve all criteria and formulary changes. The QAUMPT voting members consist entirely of providers and pharmacists from the communities we serve. Providers and members can access the current Preauthorization and Step Therapy Policies on our website at PacificSource.com/drug-list.

Requesting Preauthorization

The ordering physician or representative is required to contact our Pharmacy Services department for preauthorization. Pharmacy Services manages all drugs, whether covered by the pharmacy benefit or the medical benefit. Contact Pharmacy Services at (844) 877-4803, fax (541) 225-3665, or email pharmacy@pacificsource.com.

Electronic Prior Authorization/Inpatient Notification 2019

Beginning in 2019, PacificSource Health Plans will no longer be accepting prior authorization (PA) requests via fax or U.S. Mail. Instead, we ask that you submit prior authorization requests via our provider portal, InTouch. We will be making outreach to your offices to assist you in getting an account created, and assist with any training. 

If you do not have access to InTouch, please visit www.OneHealthPort.com and register. Here is a link with some more information about InTouch as well: PacificSource.com/aboutproviderintouch.

In some cases, your billing office may be using it already. If so, you can contact them to find out who your administrator is on the account, and they can contact OneHealthPort to have additional users added. This can include front desk personnel or anyone who needs to submit PAs.

Please do not hesitate to contact your Provider Service Representative should you have any questions. We will be happy to assist you in any training you might need to utilize this portal.

Please include relevant chart notes and lab values in all requests for preauthorization.

Please note: A member’s contract (policy) determines benefits. Prescription drugs that are contract exclusions will not be preauthorized and will not be approved via notification to the pharmacy at the time of dispensing. Drugs that are not approved may be appealed through our Customer Service department.



3 Drug Limitations

Quantity limitations are in place for some drugs. These limit drugs to specific quantities over defined time periods. The drug limitations help manage utilization and drug costs, reduce overall healthcare costs, and provide sound, cost-effective options for the choice and utilization of effective drug therapies. It also helps to prevent Fraud, Waste & Abuse of medications.

The drugs on our lists will have a limit on the quantity allowed in a 30-day period, and we can only consider claims for this limited amount. Limiting quantities helps ensure that our members are using these products appropriately and in a safe manner according to the FDA-approved dosing guidelines.

If you feel that clinical indications warrant a quantity above the limit, please contact our Pharmacy Services department for preauthorization. Please be aware, although your patient may obtain more medication than the specific dispensing limit, they may be responsible for the cost of the additional quantity.



4 Specialty Drugs

CVS Caremark® Specialty Pharmacy Services is our exclusive provider for high-cost medications and biotech drugs. Caremark’s pharmacist-led Specialty Care Team provides quality, individual follow-up care and support to our members who are utilizing specialty medications. Please visit our drug list at PacificSource.com/drug-list to determine if a particular medication is considered specialty or not.

The Specialty Care Team provides comprehensive disease education and counseling, assesses patient health status, and offers a supportive environment for patient inquiries. Through our partnership with Caremark, we not only ensure that our members receive strong clinical support, but we also ensure the best drug pricing for these specific medications.

For more information, please contact Caremark at (800) 237-2767 or fax (800) 323-2445.



5 Nonformulary Requests

If your patient has tried all formulary drugs available and requires a nonformulary drug, you may request preauthorization through the same process outlined above. If you would like to suggest an addition to the formulary, please mail your written request to:

PacificSource Health Plans
Attn: Pharmacy Services
PO Box 7068
Springfield, OR 97475-0068

The PacificSource Clinical Quality Utilization Management (CQUM) Committee and Pharmacy & Therapeutics Committee considers requests at their monthly meetings. Once we receive your request, we will notify you of the date your request will be reviewed. After the review, we will notify you of the Committee’s decision. There is no guarantee that any change will be made to the drug list.


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Last updated 1/22/2019