Pharmacy

Gainwell Technologies is the Single Pharmacy Benefit Manager (SPBM) for the Mississippi Division of Medicaid (DOM) pharmacy program. All TrueCare members receive pharmacy benefits through the SPBM.

TrueCare continues to provide coverage for provider administered drugs under the medical benefit.

Single Pharmacy Benefit Manager Pharmacy Benefits

Gainwell Technologies covers all Medicaid-covered, medically necessary prescriptions, certain over the counter (OTC) medications, vaccines, and select durable medical equipment.

Preferred Drug List (PDL)

TrueCare will post a link to the Preferred Drug List (PDL) maintained by Gainwell Technologies. It will include the Drug Formulary and PDL preferred products, in addition to preferred products in categories outside of the SUPDL. Visit the Drug Formulary page for more information.

Prior Authorization

Some drugs may require prior authorization before they will be covered. Refer to the PDL to determine which drugs need prior authorization.

Physician administered drugs billed under a member’s medical benefit may also require prior authorization.

For all prior authorization decisions (standard or urgent), TrueCare provides notice to the physician and member as expeditiously as the member’s health condition requires. Please specify if you believe the request is urgent and include all necessary clinical documentation to support expeditious review.

Policies

TrueCare pharmacy and medical policies include drug specific and therapy class policies to be used as a guide when determining health care coverage for our members.

The policies are written for those that are non-preferred, preferred with prior authorization or require step therapy. The policy is a tool to be interpreted in conjunction with the member’s specific benefit plan. Access pharmacy policies by selecting “Policies” from the Quick Links for more information.

Generic Substitution

Generic drugs approved by the Food and Drug Administration (FDA) have the same quality, strength, purity, and stability as brand name drugs. Members and providers can expect the generic to produce the same effect and have the same safety profile as the brand name drug. Generic drugs must be used, when available. If a brand name product is requested when a generic equivalent is available, you will need to request a prior authorization and explain why the member cannot use the generic drug.

Quantity Limits

Some drugs have limits on how much can be given to a member at one time. Quantity limits may be based on several factors such as drug manufacturers’ recommended dosing, patient safety, or the FDA recommendations.

Step Therapy

Sometimes, TrueCare will require a member to first try one (usually less-expensive) drug before the plan will pay for coverage of another (usually more expensive) drug for that same medical condition. This is called step therapy. Certain drugs may be covered only after step therapy is met. Please refer to the Drug Formulary <link> page for more information.

Coordinated Services Program (CSP)

CSP is a health and safety program which protects members who use of services exceeds medical necessity. Use of controlled substances is monitored, and members are assigned designated providers. A designated provider is usually a pharmacy, but may include a single prescriber, or both a single pharmacy or a single prescriber. CSP enrollees must get medications using their designated providers. In the event of an emergency and the member is unable to use the designated provider, call Member Services at 1-833-230-2050.

Drug Safety Recalls

Sometimes, a drug manufacturer or the federal government issues drug recalls. To find out if a drug you have prescribed to a patient is being recalled, please check the listings on the FDA website.