Quality and Safety Edits
In order to make our coverage accessible and affordable, Windsor Medicare Extra requires certain drugs to be authorized in advance by us. There are two types of Pharmacy Coverage Determinations. They include Prior Authorizations and Exceptions. There are also various types of Exceptions which include Quantity Limits (limits the quantities that may be routinely dispensed for some drugs), Step Therapies (for certain drugs asks doctors to prescribe less costly alternatives first, among drugs in the same category), and Non-formulary (the drug your doctor is prescribing is not included in Windsor’s formulary) exceptions.
Prior Authorizations (PA)
Windsor’s established prior authorization medications are recommended by the Windsor Pharmacy and Therapeutics Committee, which is a committee consisting of community physicians, pharmacists and nurses. Prior Approvals have been established to promote safe and appropriate cost-effective use of specific classes of medications. A prior authorization payment determination (also known as a coverage determination) is required before the member goes to the pharmacy. Please click on Coverage Determination and Exception Process for a description of the coverage determination process.
The following list represents a partial list of prior approvals in the Windsor system:
| Prior Approval Medications | |
| Arixtra | Forteo Injection |
| Avonex Injection | Lyrica |
| Betaseron Injection | Pegasys Injection |
| Boniva | Peg-Intron Injection |
| Copaxone Injection | Suboxone |
| Emend | Tarceva |
| Enbrel Injection | Testosterone |
| Exjade | Androgel |
Please consult the applicable formulary for specific PA information
Quantity Limits (QL)
Windsor’s established quantity limit medications are recommended by the Windsor Pharmacy and Therapeutics Committee, which is a committee consisting of community physicians, pharmacists and nurses. Quantity limits have been established to promote safe and appropriate cost-effective use of specific classes of medications to ensure proper dosing. All quantity limits are listed on the formulary as an established number of units per 30 days. The system will count all units received within the therapeutic class and will only allow payment of the quantity established.
The process used to establish the limit of the identified drug is the current approved Food and Drug Administration (FDA) dosing. Prescribers may request an exception to Windsor’s quantity limits by following the Exception Process.
The following list represents a partial list of quantity limits currently in the Windsor system:
| Drug Class | QL Limit |
| Zolpidem (Ambien) | 30 pills per 30 days |
| Maxalt | 12 pills per 30 days |
| Prevacid | 30 pills per 30 days |
Please consult the applicable formulary for specific quantity limit information.
Step Therapy (ST)
Windsor’s established step therapy medications are recommended by the Windsor Pharmacy and Therapeutics Committee, which is a committee consisting of community physicians, pharmacists and nurses. Step therapy medications have been established to maintain safe, effective treatment while keeping costs as low as possible. When step therapies are established, Step 2 medication will not be covered until Step 1 medications are first tried.
The following list represents a partial list of step therapies in the Windsor system:
| Step Therapy | Must try FIRST |
| Oxycontin | Morphine Sulfate ER, Kadian or Methadone |
| Zetia | Lovastatin, Simvastatin, Pravastatin, Lipitor or Crestor |
| Byetta | Anti-Diabetic Oral Medication first |
Please consult the applicable formulary for specific step therapy information.
Drug Utilization Review
The objective of Drug Utilization Review is to improve the quality of pharmaceutical care by ensuring that Prescriptions are appropriate, medically necessary, and unlikely to result in adverse medical outcomes.
Windsor seeks to ensure the safety of dispensed medications by notifying dispensing providers of potential adverse events at the point-of-dispensing when potential adverse events may occur for medications being dispensed to members. The online messaging process classifies events at different levels of severity and includes drug-to-drug interactions and therapeutic duplications. The following is a description of the DUR Program
For Therapeutic Duplications, Windsor searches for therapy that is not medically indicated and may potentially result in adverse events and sends a message back to the pharmacy regarding the alert. The system searches for overlapping periods of time that include:
- Two or more doses of the same drug
- At least two drugs from the same therapeutic class
- At least two drugs from different therapeutic classes with similar pharmacological effects being used for the same indication
Our processing system searches for drug interactions at the point-of-dispensing that may potentially result in adverse events and notifies the dispensing provider of such interactions, including their type and severity level.
Drug interactions are classified into the following severity levels:
Level 1: A potentially severe or life-threatening interaction. The occurrence has been suspected, established or probable in well controlled studies. Contraindicated drug combinations may also have this severity level.
Level 2: The interaction may cause deterioration in a patient’s clinical status. The occurrence is suspected, established or probable in well controlled studies.
Level 3: The interaction causes minor effects. The occurrence suspected, established or is probable based on well-controlled studies.
Level 4: The interaction may cause moderate-to-major effects, but data are very limited.
Level 5: Interaction may cause minor-to-moderate effects. The occurrence is unlikely or there is not good evidence of an altered clinical effect.
Messages for severity level 1 and 2 are transmitted to a dispensing provider at point of dispensing to inform the prescribing provider of the potential adverse interaction.
The Pharmacy Director analyzes drug interactions and therapeutic duplication reports every quarter for trends and may select certain alerts to send to the prescribing physician as informational.
The Pharmacy Director presents findings to the Windsor P&T Committee for further review and recommendations.
Our processing system additionally notifies the pharmacist when one of the following alerts occurs:
- Over-utilization
- Under-utilization
- Appropriate use of generic products
- Drug/disease contraindications
- Incorrect drug dosage or duration
- Drug allergy interactions
- Clinical abuse/misuse
Safety Edits
The health and safety of our members is a priority for Windsor. One of the ways we address patient safety is through point-of-sale (POS) edits at the pharmacy. These safety edits ensure that our members are utilizing their medications in a safe and effective manner and are used to prevent over utilization. The safety edits limit specific medications to the number of pills/capsules/etc that can be safely taken per day. The safety edit per day is based upon the approved FDA maximum dose for the drug. Below are two such edits currently in place.
Acetaminophen Maximum Dosing Edit
- Acetaminophen (Tylenol ®) is an over-the-counter fever reducer and pain reliever.
- It is also combined with some prescription analgesics to form prescription pain relievers such as Vicodin ® or Percocet ®.
- The maximum recommended total daily dose of Acetaminophen is 4000mg or 4gm per day. Taking more than this amount is very dangerous and can result in liver damage.
- For this reason, Windsor has implemented a hard edit to prevent medications containing acetaminophen to exceed a total daily dose of 4gms.
- If a medication containing acetaminophen is being filled for a quantity and dosage that would exceed this 4gm/day limit the prescription will reject at the point of sale at the pharmacy.
- The prescription will only go through if the acetaminophen dosage can be adjusted not to exceed the 4gm/day limit.
Atypical Antipsychotics Maximum Dosing Edit
- Atypical antipsychotics are a relatively new class of medications that are used in the treatment of schizophrenia.
- Atypical antipsychotics have less severe side effects than conventional antipsychotics that were traditionally used to treat this disease.
- The goal of treatment for schizophrenia is to use the least amount of medication possible to manage both the positive and negative symptoms effectively while limiting unwanted side effects.
- For this reason, Windsor has implemented a maximum daily dose edit for all atypical antipsychotics.
- The edits are based on the maximum recommended daily dose listed in the package insert of each product.
- If the dose exceeds the MADD edit, the prescription will reject at the point of sale at the pharmacy.
- Below is a list of these medications with the MADD.
| Drug Name | Daily Dose Edit |
| Abilify | 30mg |
| Clozaril | 900mg |
| Geodon | 160mg |
| Risperdal | 16mg |
| Seroquel | 800mg |
| Zyprexa | 20mg |
For the MTMP program, click here.
