11/21/2024

Provider Manual

Pharmacy

Note: This section applies only to QualChoice members who have MagellanRx listed as the pharmacy benefit manager on their QualChoice ID card (excluding ASO customers Dillard's and City of Hot Springs).

QualChoice uses a number of different strategies to promote the safe and appropriate use of prescription drugs. These strategies include the use of the Preferred Drug List (PDL)/Formulary, along with utilization management edits such as pre-authorization, quantity limits, step/contingent therapy, and specialty drug management.

QualChoice utilizes the standard MagellanRx formulary. The formulary can be accessed via the Pharmacy page of the QualChoice website. It provides information regarding drug coverage, tier status of the covered drugs, specialty drug designation, and utilization management edits (quantity limits, prior authorization required, age edits, etc.). Additional information available on the Pharmacy page of the QualChoice website includes:
  • MagellanRx Clinical Criteria used for evaluating PA requests
  • QualChoice General Pre-Authorization Form
  • Formulary Override Exceptions Request for External Review    

Pre-authorization (PA)

Some drugs are covered only if pre-authorized. In the PDL, these drugs are noted by (PA) beside the drug or drug category. Drugs requiring pre-authorization are reviewed based on clinical criteria developed by MagellanRx clinical staff with review by the MagellanRx National P&T Committee. 

For drug pre-authorization, contact MagellanRx, our pharmacy benefit manager, at 833-616-0136.

Step Therapy

Medications requiring step therapy are noted by (ST) in the PDL. Step therapy means that a certain drug requires use of another drug first, before it is covered. The intent of a step therapy edit is to ensure that the safest, most cost-effective medications are tried before more expensive options. When at all possible, these edits are programmed into the claims adjudication system. The member’s pharmacy history is reviewed to ensure compliance with the requirement. If this review does not show compliance, the drug will require pre-authorization.

Quantity Limits

Quantity limits ensure the safe and appropriate use of select medications by covering a specific amount that can be dispensed at one time. Quantities greater than the specified amount require pre-authorization for coverage. Drugs with quantity limits are noted by (QL or QPD) beside the drug or drug category in the PDL.

Specialty Pharmacy Management

Specialty drugs require special handling, are used to treat complex or rare health problems, and are very
costly. These drugs, including both oral and injectable products, may be dispensed by our preferred specialty
pharmacies, Magellan Specialty Pharmacy or Allcare Specialty Pharmacy. Specialty drug coverage may vary by plan.
 
Contact Magellan Specialty Pharmacy at 866-554-2673. Contact Allcare Specialty Pharmacy at 855-780-5500.

Appeals

Members have the right to appeal any adverse pharmacy benefit decision by QualChoice. The prescriber, acting on behalf of the member, may file the appeal.

New-to-Market Medications

Drugs new to the market are not covered by QualChoice until reviewed by the MagellanRx P&T Committee. Generally, all new drugs are reviewed within six months of market entry.

Formularies, Forms and Information

For current drug formularies, forms, and additional pharmacy information, see Pharmacy and Drug Formulary page. Practitioners may call 501-228-7111 to receive a copy of the pharmaceutical management procedures by mail, fax, or email.