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Pequot Pharmaceutical Network
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Pequot Pharmaceutical Network
Pharmacy Health Information Exchange

Pharmacy Benefit Management FAQs

  1. What is a PBM?
  2. A PBM is a company that administers, or handles, the prescription drug benefit component of your employer’s health plan. A PBM processes and pays for your prescription drug claims and is responsible for assisting your employer with managing the prescription benefit.

  3. What does Mandatory Mail mean?
  4. After you have had three (3) fills of a particular maintenance medication at a retail pharmacy, all future prescription refills for that medication must be obtained through PRxN mail-service pharmacy.

  5. What does Prior Authorization (PA) mean?
  6. The majority of the prescriptions presented to a pharmacy are simply filled with no questions asked. However, there are a limited number of medications that require review and approval prior to being allowed coverage by the Plan. This process is commonly referred to as “Prior Authorization”. Obtaining this authorization is necessary before the prescription can be processed.

  7. What is Step Therapy?
  8. Step Therapy is a utilization management process much like prior authorization. Step Therapy ensures that plan participants use clinically appropriate drugs in a cost effective manner.

  9. What is a MDL (quantity limits)?
  10. A Managed Drug/Dispensing Limitations (MDL) program is a mechanism to manage drug utilization and promote safe and clinically appropriate drug use within a specific therapeutic class of medications.
 
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