Pharmacy Procedures and Coverage of Drugs

INTotal Health has a list of drugs your or your child’s Primary Care Physician (PCP) or specialist can choose from to help you or your child get well. This list is called a formulary. Our formulary is updated every three months by practicing licensed pharmacists, physicians, and other licensed providers. All INTotal Health network providers and pharmacists have access to this drug list. You can find the formulary here on our webiste on the Pharmacy page under Plans & Benefits. You can also request a printed copy by calling Member Services at 1.855.323.5588 and we will mail you a copy. 

Your or your child’s PCP or specialist should use this list when he or she writes you a prescription. If we make a change to our formulary that affects you, we will send you and your provider a letter to tell you about the change. There may be times when a drug on the formulary is not the right drug for your condition.

Some of the Drugs on the Pharmacy Formulary May Have Some Limits:

Generic Substitution
Generic Drugs are approved by the U.S. Food & Drug Administration (FDA) for safety and how well they work. They are made in the same strength and dose as the brand-name drugs. If the FDA approves a drug to be switched to a generic, INTotal Health will cover the generic drug only. 

Medication Request Process
If the drug your doctor thinks you need has any of the following letters (AL, HRM, PA, QL, SP, ST) next to its name on the INTotal Health Formulary, your doctor will need to send a request to tell us about your health and why you need this drug.

Age Limits (AL)
Drugs on the formulary with AL are only covered for patients of certain ages(s).

High Risk Medications (HRM)
Drugs on the formulary with HRM for safety reasons need a pre-authorization for members age 65 years and older.

Pre-Authorization (PA)
Drugs on the formulary with PA need a pre-authorization. We will review these requests for each member.  We look at what your doctor says about your medical condition, if the FDA has approved the drug for the medical condition your doctor is treating, if you have tried other preferred drugs on the formulary or have reasons why you cannot take the preferred drugs. If we deny your request because it does not meet our guidelines, we may recommend another therapy on our formulary.

Quantity Limits (QL)
Drugs on the formulary with a QL are only covered up to a certain quantity or amount you can get a month or for each prescription. If your doctor thinks you need a quantity over this amount your doctor can make the request by sending us information about your medical condition and why you need a higher quantity.

Specialty Drugs and Injectables (SP)
Drugs on the formulary with SP are available from our Specialty Pharmacy. Some of these drugs may also need PA.  Your doctor must send your prescription to our Specialty Pharmacy and the drugs will be mailed to you.

Step Therapy (ST)
Drugs on the formulary with ST are reviewed by the computer records INTotal has for you when the pharmacy fills your prescription.  If you have filled one or more first-line drug recently the drug will be approved without you having to do anything else. If you have not filled the first-line drug then your doctor must ask for a pre-authorization.

Non-Formulary Drugs (NF)
If you have been receiving a drug not on the formulary when you joined INTotal Health, you will be able to continue to get that drug for up to three months from when you become a member with us. Your pharmacy must call the number on your card for Pharmacy Services and request this for you. During these three months, your doctor must ask for this drug for you.

If your PCP or specialist thinks you need a drug that is not on the formulary, he or she can ask us for an exception. We will respond to your provider’s request within 2 business days of receiving complete information.
You can get prescriptions and medicines from approved pharmacies in the INTotal Health network. If you do not know if a pharmacy is in the INTotal Health network, show your INTotal Health member ID card and ask the pharmacist. You can view the list of our network pharmacies here on our website on the Pharmacy page or you can also call Member Services at 1.855.323.5588 for help.
 
Pharmacy co-payments:
There are no pharmacy co-payments or deductibles for INTotal Health members with Medicaid coverage.  You can fill up to a maximum quantity of 34-day supply for each prescription at retail pharmacies.

*There are no co-payments for family planning, pregnancy-related medications and medications provided to children for all FAMIS members.