REQUEST FOR NONFORMULARY DRUG COVERAGE

If changing to a formulary medication is not medically advisable for a patient, a physician must initiate a Request for Nonformulary Drug Coverage by faxing the request form on page 7 to 1-412-255-4544 or 1-888-245-2049 during normal business hours, or call 1-800-392-1147 during off-hours and weekends, with all of the information requested on the form.

All requests for exception will receive a response within 24 hours. In the event a decision has not been made in 24 hours, Gateway Health Plan^® will authorize a temporary supply of the nonformulary medication. For new therapies, a 72-hour supply must be dispensed and for ongoing therapies, a 15-day supply of the of the nonformulary medication must be dispensed, pending the final determination of the request. Gateway Health Plan^® members have the right to appeal any decision regarding prescription drug coverage.

PHYSICIAN STATE LICENSE NUMBER

When processing a prescription claim for a Gateway Health Plan^® member, a valid physician’s state license number is required. Claims submitted without a valid physician’s state license number will be rejected at the point of sale pharmacy.

DAYS SUPPLY DISPENSING LIMITATIONS

Gateway Health Plan^® members may receive up to a 34-day supply of a pharmaceutical product per prescription order or refill. A 34-day supply shall be interpreted to mean consecutive 34-day supply, i.e., if a physician prescribes a medication b.i.d. (two times a day), a 34-day supply corresponds to a quantity of 68. The prescriber is urged to prescribe in amounts that adhere to FDA guideline and accepted standards of care. The dispensing pharmacist must accurately compute the days supply.