Pharmacy Program

The list of drugs in the formulary through Prime Therapeutics provides you with safe, effective, high-quality, cost-effective medications to ensure the best medical results. The University pharmacy managers have a strong emphasis on the use of generic medications to help control the cost of prescription drugs.

Prime Therapeutics covers a 30-day supply of prescription medications (including insulin) through network pharmacies at the following level:

• $0 copay for select preventive medications specified in the Affordable Care Act, including contraceptives in the Generic Plus category. Medica HSA covers these medications at 100%.
• $10 copay for Generic Plus (Tier 1) medications, which covers all generic drugs and certain preferred brand medications for which there is no generic therapeutic equivalent
• $30 copay for Brand Formulary (Tier 2) medications, which includes all other brand name medications listed on the formulary
• $75 copay for Non-Formulary (Tier 3) medications, which includes all covered brand name medications not listed on the formulary

For Medica HSA, prescriptions can be covered either with money from the account or applied to the annual deductible until it is met. After that, the medical plan pays 90% of the pharmacy expenses.

The University of Minnesota Formulary, found on the Prime Therapeutics website, lists the medications that are covered by the program.

Specialty drugs are provided through Fairview Specialty Pharmacy. Specialty drugs are generally prescribed for people with complex or ongoing medical conditions and the drugs themselves are often subject to unique storage or shipment requirements.

Members receive education and support from a health care professional through Fairview Specialty Pharmacy due to the complexity of use and the potential for some serious side effects.

Prime Therapeutics has a broad Minnesota and national retail pharmacy network that includes popular chains, clinic and hospital pharmacies, independent pharmacies, and a home delivery mail service pharmacy. Fairview Specialty Pharmacy provides home delivery or pick-up service for specialty drugs at Fairview clinic and hospital retail pharmacies. Specialty medications are also available through Essentia Health and Northland in Duluth.

The purpose of Medication Therapy Management is to be sure that your medications are appropriate, effective, safe, and convenient. Learn more about the MTM program on the Medication Therapy Management page.

The University medical plan has a list of medications that are covered through Prime Therapeutics for the plan. The listing is called a formulary. You can easily access the formulary on Prime's website.

A drug formulary is a continually updated listing of medications that represents the current clinical judgment of providers and pharmacists in the diagnosis and treatment of medical conditions and diseases. The medications have been selected for the University's formulary because they are safe, effective, high-quality, and cost-effective.

The formulary is developed by the Clinical Committee. The Clinical Committee includes representatives from our pharmacy benefits manager, Prime Therapeutics; pharmacists from the College of Pharmacy; and representatives from the Office of Human Resources. The Clinical Committee meets on a quarterly basis to update the formulary based on new medications that have been approved by the FDA and launched for use during the past quarter. Recommendations are made by Prime Therapeutics and approved by the full Clinical Committee, following analysis by the College of Pharmacy members.

There are three pharmacy copay levels:

• Generic Plus Medications at $10 includes all generics, plus any brand medications where there is not a generic drug in the same therapeutic class.
• Formulary Brand Medications at $30.
• Non-Formulary Brand Medications at $75.

You should first call Prime Therapeutics at 1-800-727-6181 to review any questions regarding cost discrepancies. They may be able to resolve the issue without the need for an appeal. See below to learn more about the appeals process.

• There is a set of preventive medications specified in the Affordable Care Act that have a $0 copay. This includes contraceptives in the Generic Plus category.
• If the drug actually costs less than the copay amount, you will pay the lower amount. For example: if the drug costs $7.75, you will pay $7.75 versus $10.
• If you are on the HSA, you can use your HSA account to cover all or a portion of the cost of a given prescription. Pharmacy costs are also covered at 90% after the program’s deductible.
• Medications can also be excluded on our plan; in which case the member would need to pay the full cost of the medication or ask their provider to recommend a covered alternative. See below to learn what to do if a medication you are prescribed is not covered by the formulary.

You should call the Office of Human Resources Contact Center at either 612-624-8647 or 1-800-756-2363, or email them at benefits@umn.edu. They will log your questions and refer them to Prime Therapeutics or the appropriate person at the University.

You would need to ask your doctor or other medical provider for a recommendation on another medication that is covered on the formulary. Prime Therapeutics will be able to help you determine whether a particular medication is covered. You or your doctor can call Prime Therapeutics at 1-800-727-6181.

You can call Prime Therapeutics at 1-800-727-6181 with information about the medication that you feel should be considered. They will review your recommendation in advance of the next quarterly Clinical Committee meeting to determine if the drug merits being included on the formulary, and then review it with the full Clinical Committee at the meeting. The Committee will send you a written response informing you of what was decided about the drug you recommended.

A prior authorization on a particular medication is recommended by Prime Therapeutics, and then approved by one of our pharmacists from the College of Pharmacy during or after the Clinical Committee. Anyone who takes the medication after this point will then need a prior authorization. Prior authorizations allow for review of:

• Safety when combined with other medications.
• Options for lower cost, equally effective alternatives when available.
• Assessment of limitations of a given drug, based on the health conditions of the patient.
• Potential for misuse or abuse.
• Requests for cosmetic purposes which are not covered.
• Medications that have a prior authorization (PA after the drug name on the formulary) will only be covered if your doctor requests and receives approval from Prime Therapeutics.

An appeal in our Pharmacy Program is accomplished through the Prior Authorization process. If a Prior Authorization is required for your medication, there will be a form on the Prime website that your doctor would submit for that medication. If the Prior Authorization is denied, you may choose to appeal that denial. When the denial is returned to you, you will receive the appeal form that your doctor’s office would need to complete and return to Prime Therapeutics.

If a prior authorization is denied, you will receive a new appeal form from Prime Therapeutics, attached to the denial form. You don’t need to search for the form as it is sent back to you. Your doctor’s office should complete the form you receive, following the instructions on the form, and return it to Prime Therapeutics. If the appeal form is not sent back with your denial form, you should contact Prime Therapeutics at 1-800- 727-6181 with a request for an appeal form.

Work with your doctor to make sure the form is fully filled out, and include any necessary lab work or tests to support your request. The prescriber is responsible for filling out and submitting the form, so the majority of the responsibility lies with your doctor or someone in their office.

Anyone whose prior authorization is denied may file an appeal. You have 180 days from the date of the denial letter to appeal this decision. You can also file an appeal if the medication that your provider has prescribed is not covered on the formulary.

If you appeal, Prime Therapeutics will review their decision and provide you with a written determination within 30 calendar days.

You should contact Prime Therapeutics at 1-800-727-6181. If you need additional support, you can call the University’s Contact Center at 612-624-8647 or 1-800-756- 2363. The Contact Center will forward your question to the appropriate individual at the University.

If your doctor tells Prime Therapeutics that your situation is urgent, a decision will be made as soon as possible but no later than 72 hours after they receive your request. Your situation may be urgent if you or your doctor feels your health may be in serious danger or if you are in pain that cannot be controlled while you wait for a decision. If you believe your situation is urgent, you may request an expedited appeal by following the instructions on the appeal form for an internal appeal. You may also file an external review at the same time by filling out the External Review Request form that came with your denial letter, making a copy, and sending it to Prime Therapeutics at the address below:

Prime Therapeutics LLC
2900 Ames Crossing Road
Eagan, MN 55121
Fax: 855-212-8110