Pharmacy


NextLevel Health wants you to receive all the services you need. We work with communities, providers, and Members to improve our Members’ health. NextLevel Health is committed to providing appropriate, high quality, and cost-effective drug therapy to all NextLevel Health Members. NextLevel Health works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. NextLevel Health covers prescription medications and certain over-the-counter (OTC) medications when ordered by a providers. NextLevel Health does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.

Here are quick links to access the following documents located throughout this page:

Pharmacy Benefit Manager

NextLevel Health works with Envolve Pharmacy Solutions (EPS) to process pharmacy claims for prescribed drugs. Some drugs on the NextLevel Health PDL may require PA, and Envolve Pharmacy Solutions is responsible for administering this process. EPS is our Pharmacy Benefit Manager (PBM).

Specialty Drugs

NextLevel Health contracts with a number of specialty pharmacies, such as AcariaHealth Specialty Pharmacy, to ensure members have adequate access to the specialty drugs they require. All specialty drugs, such as biopharmaceuticals and injectables, require PA to be approved for payment by NextLevel Health. PA requirements are programmed specifically to the drug.

Dispensing Limits

Drugs may be dispensed up to a maximum of thirty-four (34) day supply for each new prescription or refill. A total of 85% of the day supply must have elapsed before the prescription can be refilled for non-controlled-substance PDL drugs except for ophthalmic drugs.

Appropriate Use and Safety Edits

The health and safety of the Member are top priorities for NextLevel Health. One of the ways we address Member safety is through point-of-sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

NextLevel Health appropriate use and safety edits

Prior Authorizations

Some medications listed on the NextLevel Health PDL may require Prior Authorization (PA). The information should be submitted by the practitioner to Envolve Pharmacy Solutions on the Medication Prior Authorization Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document can be found on the NextLevel Health website.

NextLevel Health will cover the medication if it is determined that:

1
There is a medical reason the member needs the specific medication.
2
Depending on the medication, other medications on the PDL have not worked.

Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the NextLevel Health Utilization Review/Pharmacy Care Committee. If the request is approved, NextLevel Health notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, NextLevel Health will notify the Member and their practitioner of alternatives and provide information regarding the appeal process.

Step Therapy

Some medications listed on the NextLevel Health PDL may require specific medications to be used before the Member can receive the step therapy medication. If NextLevel Health has a record that the required medication was tried first the step therapy medications are automatically covered. If NextLevel Health does not have a record that the required medication was tried, the Member’s practitioner may be required to provide additional information. If authorization is not granted, NextLevel Health will notify the Member and their practitioner and provide information regarding the appeal process.

Quantity Limits

NextLevel Health may limit how much of a certain medication a member can get at one time. If the practitioner feels the Member has a medical reason for getting a greater amount, a PA may be requested. If NextLevel Health does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Age Limits

Some medications on the NextLevel Health PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Non-Preferred

NextLevel Health incorporates a PDL. A notation of ‘Non-Formulary’ corresponds to drugs identified on the NextLevel Health PDL indicating the trial and failure of preferred alternatives. The number of preferred drugs that must be tried prior to approval of non-formulary drugs varies by therapeutic drug class. To request the approval of a non-formulary drug please submit rationale via prior authorization request form to Envolve Pharmacy Solutions (fax 1-866-399-0929).

Over-the-Counter

NextLevel Health works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. NextLevel Health covers prescription medications and certain over-the-counter (OTC) medications when ordered by a practitioner. NextLevel Health does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. Click the following link to access the NextLevel Health OTC list.

Synagis® Information

RSV season is upon us. See the information below regarding Synagis® prescribing and prior authorization.

Palivizumab PA 2019-2020 Season

Synagis 2019-2020 Authorization Guidelines

Provider Communication

Mail Order Pharmacy Information

Mail Order Pharmacy Brochure

Mail Order Pharmacy Enrollment Form