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Pharmacy Management

SummaCare's Prescription Drug Benefit incorporates utilization management programs that apply restrictions on certain drugs. Utilization management restrictions include, but are not limited to, prior authorization, step therapy and quantity limits.

Step Therapy

Step Therapy is the practice of beginning drug therapy for a medical condition with the most cost-effective and safest drug and progressing to other more costly or risky therapy, only if necessary (i.e., you must try drug "A" before you can get drug "B"). The goal is to control costs and minimize risks. Step therapy is an automated process. If a prescription is presented for a "step therapy" drug (i.e., "B") to a pharmacy, an automated check of the member's prescription history will occur. If the system finds that the member has received the qualifying drug(s) (i.e., "A"), the prescription will be processed. If the system does not find the qualifying drug (i.e., "A") in the member's recent history, a prior authorization will be necessary. The step therapy guidelines are developed and reviewed by a panel of practicing physicians and pharmacists.

Quantity Limits

When a drug has a quantity limit, the amount of medication per prescription is limited to a specified amount per 30 days. These limitations may be in place due to safety issues or because the use of a dose higher than what is recommended has been shown to result in minimal additional benefit to the patient. Requests for increased quantities are only approved when the guidelines below are met. Quantity limit guidelines are developed and approved by a panel of practicing physicians and pharmacists.

Prior Authorization

Prior Authorization is required for the certain medications because they may have limited conditions for which they are prescribed; special monitoring or dispensing requirements; or an extremely high cost. Guidelines for approving coverage for prior authorization drugs are developed and approved by a panel of practicing physicians and pharmacists.

Use our online tool to find your drug name and view specific step therapy, quantity limits or prior authorization guidelines.

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Provider Support Services

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Provider Engagement Specialists

If you have not met with your assigned Provider Engagement Specialist or would like to schedule an in-office training or meeting to address any questions regarding the authorization process, claims issues, appeals, SummaCare products/benefits or Plan Central training, please contact the assigned Provider Engagement Specialist for your office.

Plan Central

View patient eligibility, benefits, claims status, and self-funded prior authorization lists, as well as review clinical edits and clarifications.