Medco is WHA's Pharmacy Benefit Manager (PBM) and has been delegated responsibility for administering pharmacy benefits for Western Health Advantage (WHA). Plan level staff process both provider and member appeals related to pharmacy benefit issues. For general information about Medco services, see their website: www.medco.com.
List of Covered Medications
Preferred Drug List
Western Health Advantage has a Preferred Drug List (PDL) based on a multiple tier incentive design. The PDL lists preferred generic drugs, which have a first tier copayment, and preferred brand name drugs with a second tier copayment. Drugs not listed on the PDL and the brand name counterparts to the listed generic medications have a third tier copayment, but do not require a Prior Authorization. Specialty drugs, oral and self-injectable medications are not listed on the PDL. All Specialty drugs require Prior Authorization and have a Specialty copayment. The PDL is accessible to both members and providers on WHA's website. You may also request a copy of WHA's PDL by calling Member Services at (916) 563-2250 or toll free at (888) 563-2250.
WHA requires the generic product be dispensed for all multi-source brand name drugs unless the physician specifies, "dispense as written" (DAW). DAW requests must comply with all regulations of the California Board of Pharmacy.
Except for Specialty drugs, most oral drugs do not require Prior Authorization. If Prior Authorization is required, requests must be submitted to Medco for coverage determination. Requests for coverage of Vfend should be sent to Western Health Advantage.
Step Therapy with ACE inhibitors is required for coverage of ARB drugs.
Prior Authorization for Self-Injectables
All self-injectable medications, except for insulin, require Prior Authorization for coverage. Prior authorization requests for self-injectable medications vary by the patient's medical group/IPA. The following briefly explains the process to follow when considering authorization requirements.
Hill Physicians Medical Group or NorthBay Medical Group: Fax authorization requests directly to Western Health Advantage at (916) 568-5280.
UC Davis Medical Group: Authorization request should be entered into the on-line Managed Care (MC00) system for review. Also, please note that UC Davis members must fill their prescriptions for self-injectable medications at a UC Davis campus pharmacy.
Mercy Medical Group (including Woodland patients): Authorization requests should be entered into the Mercy Authorization System IDX for review.
WHA allows the approval of the off-label use of drugs if the following criteria are met. WHA recommends that the Medical Groups' Utilization Management department review the request prior to submission to the WHA Utilization Management Nurse or Clinical Pharmacist for review and coverage determination. All potential coverage denials must be reviewed by WHA's Medical Director. Factors to be considered for approval include, but are not limited to:
The drug is approved by the FDA for at least one indication.
The drug is prescribed by a participating licensed health care professional.
The drug has been recognized for treatment of that specific condition by one of the following:
The American Hospital Formulary Service Drug Information.
The United States Pharmacopoeia Dispensing Information, Volume 1, Drug Information for the Health Care Professional.
Two articles from major peer-reviewed medical journals that present data supporting the proposed off-label use or uses as generally safe and effective, unless there is clear and convincing contradictory evidence presented in a major peer-reviewed medical journal.
Vacation Supply of Medication/Lost Medication
WHA allows the approval of a 30-day supply of medication to cover a patient's vacation. The dispensing pharmacy can approve a 30 day vacation override once every calendar year by entering the appropriate code into the claims adjudication computer system. More than one request per year will be referred to Medical Management for review.
All requests for controlled substances will be referred to Medical Management for review before a vacation override is authorized.
Western Health Advantage is not responsible for replacing lost or stolen medication.
Members can obtain most of their prescription medications at any participating retail pharmacy. To assist your patients with locating a list of participating retail pharmacies please refer them to WHA's online provider directory or direct them to the Medco website at www.medco.com . You and your patients are also welcome to call Medco directly at (800) 903-8664.
Your patients can save both time and money by utilizing Medco's mail-order pharmacy program, whereby prescriptions can be refilled by phone or online and will be delivered to the member's home or office.
WHA encourages its members to register on the Medco website at www.medco.com in order to take advantage of their online services. Registered members can order refills and renew prescriptions easily; view up to 12 months of prescription history; review pharmacy benefit plan highlights; compare pharmacy coverage and pricing; and access health and wellness information 24 hours a day, 7 days a week.