What's the difference between brand-name drugs and generic drugs?
A brand-name drug is protected by a patent for a certain amount of time. That means only one manufacturer can make the drug during that time. Once the patent expires, generic versions of the drug are often introduced.
Generic drugs have the same active ingredients as their brand-name counterpart and must meet the same quality standards as brand-name drugs, but are generally less expensive.
Both brand-name and generic drugs are regulated by the Food and Drug Administration (FDA).
Does the drug list ever change?
Yes. A team of physicians and pharmacists regularly reviews new and existing drugs to be sure the drug list continues to meet the needs of our members and providers. Drugs may be added to the list at any time during the year; however, Medica strives to limit removing drugs to no more than twice a year.
If a generic equivalent becomes available for a brand-name medication on our drug list, we may update the list to only include the generic as the preferred drug. If a change to the list affects a drug you are taking, we'll send you a letter telling you about the change.
What are drug quantity limits?
A quantity limit is a maximum amount of a drug that is allowed to be filled during a specific period of time. For example, 60 tablets per month. Drugs that have a quantity limit are noted on the drug list.
What is a specialty drug?
Specialty drugs are used to treat certain complex health problems. These drugs tend to be very expensive and may need special handling and monitoring. For most specialty medications, you'll use a Hennepin Healthcare Pharmacy.
If you need to fill a new specialty drug:
- Check the specialty drug list, which shows all of the medications Medica considers specialty drugs.
- Your plan may not cover all of the drugs on the specialty drug list, so check your coverage document on mymedica.com, or call the Customer Service number on the back of your Medica ID card for your specific benefits.
- Once you've verified your benefits, have your prescription filled through a Hennepin Healthcare Pharmacy.
Call your Hennepin Healthcare Pharmacy for more information.
What is Step Therapy?
Step Therapy is a program focused on using cost-effective prescription drugs as first-line treatment when appropriate. The program is used for certain conditions where there are many treatment options available. Drugs that require Step Therapy are noted on the drug list.
In Step Therapy, you try the Step 1 preferred drug or drugs first. Step 1 drugs are cost efficient and effective options. If the Step 1 drug isn't effective, you can then try the Step 2 drug. In some cases, you may need to try more than one Step 1 drug before trying a Step 2 drug.
Step Therapy applies to all members, regardless of their plan type. That means that if you don't try the Step 1 drug or drugs first, then a Step 2 drug won't be covered. Your doctor can request an exception to this process.
What is Prior Authorization?
Prior Authorization is approval given by Medica for coverage of a certain medication. Medications that require Prior Authorization are noted on the drug list with a "PA" next to the drug name. As a provider in the Medica network, your doctor will know how to request Prior Authorization.
What if I need a drug that's not on the drug list?
Your doctor can request an exception to the drug list by faxing a completed Exception Request Form.
Your doctor should provide all the requested information, including which medications have been tried and didn't work (e.g. dosage information and reason for failure, such as side effects lack of efficacy, etc.).
Can I appeal if an exception request is denied?
Yes. If your exception request is denied, Medica will send you a letter explaining your right to appeal and the process for the appeal.