Drug Edits

Question 1

SP

Answer 1

Specialty medications are indicated with SP on a formulary. Specialty Pharmacies specialize in medications for chronic disease management, medications only approved to be dispensed by select pharmacies, and many injectable medications. This pharmacy also ships all medication. When a medication is coded with “SP” members can choose to order through the specialty pharmacy or have it ordered through retail.

Question 2

PA

Answer 2

Prior Authorization (medical criteria) required

Question 3

ST

Answer 3

Step Therapy required; trial and failure of a specific number of preferred medications. The formulary will indicate the preferred options.

Question 4

QL

Answer 4

Quantity Limit required; the plan is willing to cover the medication at a specific dose/amount in a given time-frame.

Question 5

NC

Answer 5

Not Covered; members are referred to items on the formulary that are covered, or are given the option to request coverage through the plan with an Exception to Coverage form.

Question 6

MSP

Answer 6

Mandatory Specialty Pharmacy medication; this medications must be filled by the specialty pharmacy designated by the plan, though many times a plan will allow a first fill at retail so that the patient can start the medication faster.