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Preferred Drug List

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Preferred Drug List Comprehensive PREFERRED DRUG LIST Coordinated Care Pharmacy Program Coordinated Care is committed to providing appropriate, high quality, and cost effective drug therapy to all Coordinated Care members. Coordinated Care works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Coordinated Care covers prescription medications and certain over-the-counter (OTC) medications when ordered by a Washington Medicaid enrolled, Coordinated Care practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. Apple Health Core Connections Coordinated Care has been selected as the statewide managed care health plan to run the Apple Health Foster Care program starting April 1, 2016. The Apple Health Core Connections program is a new managed care program. Preferred Drug List The Coordinated Care Preferred Drug List (PDL) is a list of covered drugs. The PDL is a list of drugs members can receive at retail pharmacies. The Coordinated Care PDL is continually evaluated by the Coordinated Care Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The P&T Committee is composed of the Coordinated Care Medical Director, Coordinated Care Pharmacy Program Director, and several Washington primary care physicians and specialists. Pharmacy Benefit Manager Coordinated Care works with Envolve Pharmacy Solutions to process all pharmacy claims for prescribed drugs. Envolve Pharmacy Solutions is Coordinated Care’s Pharmacy Benefit Manager (PBM). Some drugs on the Coordinated Care PDL require a PA and Envolve Pharmacy Solutions is responsible for administering the PA process. Specialty Pharmacy Program Certain medications are only covered when supplied by Coordinated Care’s specialty pharmacy provider. AcariaHealth is the preferred specialty pharmacy provider of Coordinated Care. All specialty drugs, such as biopharmaceuticals and injectables, require a PA to be approved for payment by Coordinated Care. Coordinated Care’s Medical Director and Pharmacy Director oversee the clinical review of these PA requests. AcariaHealth provides the following services: A dedicated, multilingual team available 24 hours a day, 7 days a week to meet the unique needs of each patient. Disease-specific product education and training Customized treatment programs and compliance monitoring Prior authorization support Timely delivery to the physician’s office or the patient’s home, as requested Drug or disease state specific prior authorization forms will be available on Coordinated Care’s website. Dispensing Limits Drugs may be dispensed up to a maximum of a 34 day supply for each new prescription or refill. A total of 85% of the day supply must elapse before a prescription can be refilled. Maintenance Drug Program Members can obtain a 90 day supply (3 month supply) of maintenance drugs from participating pharmacies. Maintenance medications are used to treat long-term conditions or illnesses. Additional information about the Maintenance Drug Program, including a list of “Maintenance Medications” and participating pharmacies can be found at www.coordinatedcarehealth.com/for-providers/pharmacy- program/ Members may request their practitioner to transfer a current prescription or phone in a prescription directly to Coordinated Care’s mail order pharmacy, Homescripts. Homescripts may be reached at 1- 800-785-4197. Members may also have their extended supply of maintenance medications filled at a Coordinated Care network pharmacy. Appropriate Use and Safety Edits The health and safety of the member is a priority of Coordinated Care. One of the ways we address member safety is through point-of-sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization. Additional information about the drugs that are part of the Appropriate Use and Safety Edits can be found in the Appropriate Use and Safety Edits document located on the Coordinated Care website at www.coordinatedcarehealth.com/for-providers/pharmacy-program/ Second Opinion Network (SON) Washington’s Health Care Authority (HCA) implemented a drug initiative, called the Second Opinion Network (SON). The goal is to reduce therapeutic duplications of psychotropic drugs prescribed to children 17 years of age and younger. Coordinated Care has adopted the guidelines for age limitations and dosing limitations set forth by Washington’s HCA. Members (17 years of age and younger) who are prescribed medications outside these guidelines for the “first time”, or prescribed prescriptions with “dose escalations”, will be referred by Coordinated Care to the HCA to initiate the process of the second opinion review. After the second opinion review has been completed by the HCA, Coordinated Care will receive a copy of the “SON” from the HCA. The “SON” will have recommendations explaining the approval or unable to approve determination of the psychotropic prescription request. Opioid Policy Effective November 1, 2019, Apple Health will apply a safety limit to the total daily dose of opioids. The dose of different opioids is measured in units called morphine milligram equivalents (MME). An opioid prescription or combinations of opioid prescriptions that exceed a daily dose equal to 120 MME will require the prescriber to complete and sign an opioid attestation form. This safety limit helps ensure prescribers are following best practices. Prior Authorizations If a medication is not listed on the PDL, a Prior Authorization (PA) outlining the Medical Necessity for the drug is needed (please see Medical Necessity Requests information below). Furthermore, some medications listed on the Coordinated Care PDL may require a PA. The information should be submitted by the practitioner or pharmacist to Envolve Pharmacy Solutions on the Medication Prior Authorization Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document is located on the Coordinated Care website at www.coordinatedcarehealth.com/for- providers/pharmacy-program/ In addition, Providers and Pharmacists can conduct a telephonic prior authorization via phone at 855-757-6565, from 5am – 5pm Pacific Time, Monday through Friday, for all non-specialty drugs. You can visit www.coordinatedcarehealth.com/for-providers/pharmacy-program/ for more details. Coordinated Care will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. All reviews are performed by a licensed clinical pharmacist using the criteria established by the Coordinated Care P&T Committee. Once approved, Envolve Pharmacy Solutions notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Coordinated Care will notify the member and their practitioner of alternatives and provide information regarding the appeal process. Step Therapy Some medications listed on the Coordinated Care PDL may require specific medications to be used before the member can receive the step therapy medication. If Coordinated Care has a record that the required medication was tried first, the step therapy medications are automatically covered. If Coordinated Care does not have a record that the required medication was tried, the member and their practitioner may be required to provide additional information. If Coordinated Care does not grant a PA, then Coordinated Care will notify the member and their practitioner and provide information regarding the appeal process. Quantity Limits Coordinated Care may limit how much of a medication a member can get at one time. If the practitioner feels that the member has a medical reason for getting a larger amount, then the practitioner can submit a PA. If Coordinated Care does not grant a PA, Coordinated Care will notify the member and their practitioner and provide information regarding the appeal process. Age Limits Some medications on the Coordinated Care PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals. Medical Necessity Requests If a member requires a medication that does not appear on the PDL, then the member or member’s practitioner can make a medical necessity request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. Coordinated Care requires: -Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or - Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or - Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. All reviews are performed by a licensed clinical pharmacist using the criteria established by the Coordinated Care P&T Committee.
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