Pharmacy

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

Pharmacy Benefit Manager

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

Specialty Drugs

NLH 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 NLH. 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 NLH. 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.

Prior Authorizations

Some medications listed on the NLH 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 NLH website.

NLH 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 NLH Utilization Review/Pharmacy Care Committee. If the request is approved, NLH notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, NLH will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Step Therapy

Some medications listed on the NLH PDL may require specific medications to be used before the member can receive the step therapy medication. If NLH has a record that the required medication was tried first the step therapy medications are automatically covered. If NLH 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, NLH will notify the member and their practitioner and provide information regarding the appeal process.

Quantity Limits

NLH 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 NLH 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 NLH 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

NLH incorporates a Preferred Drug List. A notation of ‘Non-Formulary’ corresponds to drugs identified on the NLH 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).