Health Partners Medicaid
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Health Partners Plans Formulary Updated 12/6/2016 2017 Formulary Introduction (P&T) Committee supply must be accurately determined by the dispensing pharmacist to assure compliance with plan parameters. Health Partners Plans, Inc. is pleased to The actions of the Health Partners Plans Specific limits based on FDA guidelines, provide the 2017 Formulary. This formulary P&T Committee are communicated medication package inserts and accepted covers members under Health Partners through the Provider Newsletter to all standards of care may apply to medication Plans Medicaid plan. The drugs listed in the physicians and posted on our website. treatments under clinical review. Health Partners Plans Formulary are Pharmacy providers in the Health Prescription quantities cannot be altered intended to provide sufficient options to treat Partners Plans network will be notified unless approved by the physician, and must the majority of patients who require drug through correspondence from the Health be within the limits of the plan’s days supply. therapy in an ambulatory setting. Excluded Partners Plans pharmacy department. Prescribed medications or regimens that are from coverage are specific manufacturers non-formulary require prior authorization. who have not contracted with the rebate Product Selection Criteria program of the Federal government. The drugs listed in the Health Partners Immediate Need (5/15-day The Health Partners Plans P&T Committee Plans Formulary have been reviewed and Emergency Supply) approved by the Health Partners Plans will consider all FDA approved drugs for Pharmacy and Therapeutics Committee. inclusion in the formulary. The evaluation If a member presents at a pharmacy a These drug products have been selected to process includes a literature review; expert prescription which requires prior provide the most clinically appropriate opinion by respected medical professionals authorization, whether for a non-formulary and cost-effective medications for Health or through TEC (Technical Evaluation drug or otherwise, and if the prior Partners Plans members. There may be Center) may also be sought. Formal reviews authorization cannot be processed occasions when an unlisted drug is desired are prepared which typically address the immediately, Health Partners Plans will for medical management of a specific following information: allow the pharmacy to dispense an interim patient. In those instances, the unlisted 1. Safety supply of the prescription under the medication may be requested through Prior 2. Effectiveness following circumstances: Authorization/ Medical Exception. 3. Comparison studies 4. Approved indications If the recipient is in immediate need of the 5. Adverse effects medication in the professional judgment of Preface 6. Contraindications the pharmacist and if the prescription is for a 7. Pharmacokinetics new medication (one that the recipient has The Health Partners Plans Formulary is 8. Patient compliance considerations not taken before or that is taken for an acute organized by sections, which refer to either 9. Medical outcome and condition), Health Partners Plans will allow a drug/ pharmacologic class or disease pharmacoeconomic studies the pharmacy to dispense a 5-day supply of state. Each section contains a list of drugs When a new drug is considered for the medication to afford the recipient or selected to be on this formulary. Prescribing formulary inclusion an attempt will be made pharmacy the opportunity to initiate the a drug product that is available generically is to examine the drug relative to similar drugs request for prior authorization. encouraged when appropriate. currently on formulary. In addition, entire If the prescription is for an ongoing Prescriptions for generically available non- therapeutic classes are periodically medication (one that is continuously prescription (OTC) drugs deemed medically reviewed. This review process may result in prescribed for the treatment of an illness or necessary by the plan are eligible for deletion of a drug(s) in a particular condition that is chronic in nature in which coverage. Generally, OTC medications are therapeutic class in an effort to continually there has not been a break in treatment for less costly than prescription alternatives and promote the most clinically useful and cost- greater than 34 Days), Health Partners their use can contribute to cost-effective effective agents. Plans will allow the pharmacy to dispense a therapy. The over-the-counter (OTC) 15-day supply of the medication products listed in the formulary are covered Plan Limits automatically, unless Health Partners Plans with a prescription. mailed to the member, with a copy to the A maximum of 30-day supply of medication prescriber, an advanced written notice of the is eligible for coverage. The prescriber is reduction or termination of the medication at urged to prescribe in amounts that adhere to least 10 days prior to the end of the period for which the medication was previously Pharmacy and Therapeutics accepted standards of care. The days authorized. i Health Partners Plans Formulary Updated 12/6/2016 Health Partners Plans will respond to the strength and dosage form as the brand specific products. These medications may request for prior authorization within 24 name counterpart. require Prior Authorization for the following hours from when the request was received. The FDA has given the generic an “A” rating reasons: If the prior authorization is denied, the compared to the branded counterpart Non-formulary medications, or benefit recipient is entitled to appeal the decision indicating bioequivalence and has exceptions required by medical through several avenues. The 5-day or 15- determined the generic is therapeutically necessity day requirement does not apply when the equivalent to the referenced brand. The All brand name medications when pharmacist determines that taking the ratings of generic drugs are available by there is an A-rated generic equivalent medication, either alone or along with other referring to the FDA reference Approved available medication that the recipient may be taking, Drug Products with Therapeutic Equivalence Medications and/or treatments under would jeopardize the health and safety of Evaluations (Orange Book). clinical investigation the recipient. When the above two criteria are met, a Medications used for non-FDA generic can be substituted with the full approved indications expectation that the substituted product will Formulary Product Prescription costs that exceed $1000 produce the same clinical effect and safety Descriptions per claim profile as the brand name product. Prescriptions that exceed set plan State laws or regulation may indicate the limits (days supply, quantity, cost) This formulary lists all specific strengths and ability to practice generic substitution for Prescriptions processed by non- dosage forms that are covered. When a selected products or categories of drugs. network pharmacies strength or dosage form is specified, There are now many brand name products New-to-market products only the product identified will be that are repackaged or distributed under a High end oral and self administered covered. Other strengths/ dosage forms generic label. These generic versions injectable medications of the referenced product are not should always be considered therapeutically covered. equivalent and substitutable for the source Medications with Health Partners For specific questions please contact the branded product irrespective of rating. Plans P&T Committee approved treatment guidelines Health Partners Plans Pharmacy department at 215-991-4300. Drugs Efficacy Study To request a prior authorization the Implementation (DESI) Drugs physician or a member of his/her staff Generic Substitution should contact Health Partners Plans Health Partners Plans does not reimburse either by fax at (866) 240-3712, or phone Generic substitution is the process by which for DESI drugs. DESI drugs are those drugs at (215) 991-4300. All non-emergency a generic equivalent is dispensed rather first marketed between 1938 and 1962 requests can be faxed 24 hours per day; than the brand name product. The which were approved as safe, but not calls should be placed from 9:00 A.M. to appropriate use of generic drugs is one required to show effectiveness for FDA 5:00 P.M., Monday through Friday. method of providing cost conscious drug product approval. The DESI program In the event of an immediate need after therapy. Health Partners Plans will not subsequently made a determination of fully business hours, the call should be made to cover any drugs by companies that do not effective for most of these products and they Health Partners Plans Member Services at participate in the Federal Rebate Program remain in the marketplace. A few DESI (800) 553-0784. The call will be evaluated or are DESI drugs. Generic drugs must be products remain classified as less than fully and routed to a pharmacist-on-call. prescribed and dispensed when an A-rated effective while awaiting final administrative The physician may use the Health Partners generic drug is available. Brand necessary disposition. Also classified as DESI are Plans Prior Authorization/Medical Exception prescriptions for drugs with A-rated generics many products listed as identical, similar, or form or a letter of request, but must include require prior authorization. related to actual DESI products. the following information for quick and The MAC list sets a ceiling price for the Examples