Pharmacy Benefit Management

Topics	First Fill Program	Forms & Publications	Service Guide for Pharmacists
Pharmacy Overview	Sign Up Process	Prior Authorization Form (M3)	Quick Reference Sheet
US Script	Pharmacy Fee Schedule	Formulary/Product Resrictions	Brand Medication Prior Authorization Form (P2)
Plan Benefits	Generic Dispensing	Drug Quantity Limits	Relistor Prior Authorization Form (P3)
Plan Design		First Fill Product Restrictions	DAW1 Policy Statement
		Sample Narcotic Contract

Plan Design

Days Supply Limits

Supplies will be limited to 34 days for acute and 60 days for chronic medication

Drug Quantity Limits

For a complete list of limits go to Drug Quantity Limits

Formulary/Product Restrictions

Medication generally excluded from coverage; however, on specific cases approval may be given. Prior authorization is required by the pharmacy director.
For a complete list of restricted medications go to Formulary/Product Restrictions

Charges for Durable Medical Equipment (DME) or supply items (i.e. gauze, tape etc.) need to be submitted to WSI in paper format or electronically in the CMS 1500 format.
Generic dispensing requirements (generic medication must be dispensed)

If prescribing a medication on the restricted list, prior authorization is required. This process can be initiated in two ways:

Physician ordering the script can complete and submit the M3 form
Pharmacist attempting to fill the script can call WSI

The Service Guide for Pharmacists outlines when to contact US Script and when to contact WSI. The Pharmacy Program Quick Reference Sheet provides further explanation about the online messages the pharmacy receives at the point-of-sale.

Contact Information: Harvey Hanel PharmD
Pharmacy Director
Workforce Safety & Insurance
1-800-440-3796 ext 87222#
1-701-328-7222
Fax 1-701-328-3793
hhanel@nd.gov