Safe Prescribing Procedures

In addition to our prior authorization program, FutureScripts has established a number of additional utilization management procedures to allow for the safest and most effective prescription usage for our plan participants.

Age and Gender Limits

The FDA has established specific procedures that govern prescribing practices. These rules are designed to prevent potential harm to patients and ensure that the medication is prescribed according to Food & Drug Association (FDA) guidelines. For example, some drugs are approved by the FDA only for individuals age 14 and older, such as ciprofloxacin, or prescribed only for females, such as prenatal vitamins. The pharmacist’s computer provides up-to-date information about FDA rules. If the plan participants’s prescription falls outside of the FDA guidelines, it will not be covered until prior authorization is obtained. Physicians may request preapproval of restricted medications when medically necessary.

Quantity Level Limits

Quantity level limits are designed to allow a sufficient supply of medication based on FDA-approved maximum daily doses and length of therapy of a particular drug.

The first type of quantity limit is based on a 30-day supply of a medication per fill. Examples of quantity level limits per fill include:

  • Avonex® (one kit/four injections)
  • Betaseron® (15 vials)
  • Copaxone® (32 vials)
  • Rebif® (12 injections)
  • sedative-hypnotic drugs, such as Sonata® (14 capsules) and Ambien® (14 tablets)
  • oral narcotic drugs, such as OxyContin® (90 units), Percodan® (180 units), and Percocet® (180 units)

If the prescription exceeds the quantity limit, the pharmacist will fill for the allowed supply and then the plan participants must follow up with his or her physician regarding future prescriptions. The prescribing physician may request a quantity limit override if the plan participant’s therapy requires a larger daily dose of medication.

Another type of quantity limit is based on FDA dosing guidelines over a rolling 30-day period. Quantity level limits per a rolling 30-day period apply to migraine medications, such as Amerge® (nine 2.5mg tablets), Imitrex® (36 50mg tablets), Maxalt® (12 10mg tablets), Migranal® (eight 4mg nasal spray units), Stadol NS® (four 10mg units), and Zomig® (nine 5mg tablets). In addition, some fertility agents (if covered under the group contract) are included in the rolling edits, such as Fertinex®, Follistim®, Gonal F®, Humegon®, Pergonal®, and Repronex® (all at 60 ampules).

If the quantity of medication prescribed exceeds the quantity level limit, the prescribing physician must submit supporting information to FutureScripts that demonstrates the need for an increased quantity. Physicians should initiate a request for a quantity override. The purpose of these limits is to make certain that these drugs are used as prescribed.

Another type of quantity level limit is the “Refill Too Soon” edit. If a plan participant used less then 75 percent of the total day supply of a previously filled prescription, the refill request will be rejected at the pharmacy. This limit helps promote that medication is being taken in accordance with the prescribed dose and frequency of administration.