Health Partners Plans CHIP Formulary Updated 01/01/2021 2021 Formulary Introduction be notified through correspondence from Prescription quantities cannot be altered unless the Health Partners Plans Pharmacy approved by the physician, and must be within department when applicable. the limits of the plan’s days’ supply. Health Partners Plans, Inc. is pleased to provide the 2021 KidzPartners Formulary. This Prescribed medications or regimens that are formulary covers members under the Product Selection Criteria non-formulary require prior authorization. KidzPartners (Children’s Health Insurance Program) plan. The drugs listed in the The Health Partners Plans P&T Committee will KidzPartners Formulary are intended to provide consider all FDA approved drugs for inclusion Immediate Need sufficient options to treat the majority of in the formulary. The evaluation process (5/15-day Emergency Supply) patients who require drug therapy in an includes a literature review, and expert opinion ambulatory setting. Excluded from coverage by respected medical professionals. Formal If a member presents at a pharmacy with a are drugs from specific manufacturers who reviews are prepared which typically address prescription which requires prior authorization, have not contracted with the rebate program of the following information: whether for a non-formulary drug or otherwise, the Federal government. 1. Safety and if the prior authorization cannot be 2. Effectiveness processed immediately, Health Partners Plans The drugs listed in the KidzPartners Formulary will allow the pharmacy to dispense an interim have been reviewed and approved by the 3. Comparison studies 4. Approved indications supply of the prescription under the following Health Partners Plans Pharmacy and circumstances: Therapeutics Committee. These drug products 5. Adverse effects have been selected to provide the most 6. Contraindications If the recipient is in immediate need of the clinically appropriate and cost-effective 7. Pharmacokinetics medication in the professional judgment of the medications for KidzPartners members. There 8. Patient compliance considerations pharmacist and if the prescription is for a new may be occasions when an unlisted drug is 9. Medical outcome and medication (one that the recipient has not taken desired for medical management of a specific pharmacoeconomic studies before or that is taken for an acute condition), patient. In those instances, the unlisted Health Partners Plans will allow the pharmacy medication may be requested through Prior When a new drug is considered for formulary to dispense a 5-day supply of the medication to Authorization/ Medical Exception. inclusion, an attempt will be made to examine afford the recipient or pharmacy the opportunity the drug relative to similar drugs currently on to initiate the request for prior authorization. formulary. In addition, entire therapeutic Preface classes are periodically reviewed. This review If the prescription is for an ongoing medication process may result in deletion of a drug(s) in a (one that is continuously prescribed for the The KidzPartners Formulary is organized by particular therapeutic class in an effort to treatment of an illness or condition that is sections, which refer to either a drug/ continually promote the most clinically useful chronic in nature in which there has not been a pharmacologic class or disease state. Each and cost-effective agents. break in treatment for greater than 30 Days), section contains a list of drugs selected to be Health Partners Plans will allow the pharmacy on this formulary. Prescribing a drug product Plan Limits to dispense a 15-day supply of the medication that is available generically is encouraged automatically, unless Health Partners Plans when appropriate. Unless exceptions are mailed to the member, with a copy to the noted, all applicable dosage forms and A maximum of up to a 30-day supply of prescriber, an advance written notice of the strengths of the referenced product generally medication is eligible for coverage. The reduction or termination of the medication at are covered. prescriber is urged to prescribe in amounts that least 10 days prior to the end of the period for adhere to accepted standards of care. The which the medication was previously days’ supply must be accurately determined by authorized. Pharmacy and Therapeutics the dispensing pharmacist to assure (P&T) Committee compliance with plan parameters. Health Partners Plans will respond to the Specific limits based on FDA guidelines, request for prior authorization within 24 hours The actions of the Health Partners Plans medication package inserts and accepted from when the request was received. If the P&T Committee are communicated through standards of care may apply to medication prior authorization is denied, the member is the Provider Newsletter to all physicians treatments under clinical review. entitled to appeal the decision through several and posted on our website. Pharmacy avenues. The 5-day or 15-day requirement providers in the KidzPartners network will does not apply when the pharmacist Health Partners Plans CHIP Formulary Updated 01/01/2021 determines that taking the medication, either When the above two criteria are met, a generic • Medications used for non-FDA approved alone or along with other medication that the can be substituted with the full expectation that indications recipient may be taking, would jeopardize the the substituted product will produce the same • Prescription costs that exceed $1,000 health and safety of the recipient. clinical effect and safety profile as the brand per claim name product. • Prescriptions that exceed set plan limits Formulary Product (days’ supply, quantity, cost) State laws or regulation may indicate the ability Descriptions • Prescriptions processed by non-network to practice generic substitution for selected pharmacies products or categories of drugs. This formulary lists all specific strengths and • New-to-market products • High-end oral and self-administered dosage forms that are covered. When a There are now many brand name products that strength or dosage form is specified, only injectable medications are repackaged or distributed under a generic • Medications with Health Partners Plans the product identified will be covered. Other label. These generic versions should always be strengths/ dosage forms of the referenced P&T Committee approved treatment considered therapeutically equivalent and guidelines product are not covered. substitutable for the source branded product irrespective of rating. To request a prior authorization the For specific questions please contact the physician or a member of his/her staff Health Partners Plans Pharmacy department at Drugs Efficacy Study should contact Health Partners Plans either 215-991-4300. by fax at 866-240-3712, or phone at 215-991- Implementation (DESI) Drugs 4300. All non-emergency requests can be Generic Substitution faxed 24 hours per day; calls should be Health Partners Plans does not reimburse for placed from 9:00 A.M. to 6:00 P.M., Monday DESI drugs. DESI drugs are those drugs first Generic substitution is the process by which a through Friday. marketed between 1938 and 1962 which were generic equivalent is dispensed rather than the approved as safe, but not required to show brand name product. The appropriate use of In the event of an immediate need after effectiveness for FDA product approval. The generic drugs is one method of providing cost business hours, the call should be made to DESI program subsequently made a conscious drug therapy. Health Partners Plans KidzPartners Member Relations at determination of fully effective for most of these will not cover any drugs by companies that do 1-888-888-1212. The call will be evaluated and products and they remain in the marketplace. A not participate in the Federal Rebate Program routed to a pharmacist-on-call. few DESI products remain classified as less or are DESI drugs. Generic drugs must be than fully effective while awaiting final prescribed and dispensed when an A-rated The physician may use the Health Partners administrative disposition. Also classified as generic drug is available. Brand necessary Plans Prior Authorization/Medical Exception DESI are many products listed as identical, prescriptions for drugs with A-rated generics form or a letter of request, but must include the similar, or related to actual DESI products. require prior authorization. following information for quick and appropriate review to take place: Examples of DESI Drugs include: The MAC list sets a ceiling price for the Midrin • Name and recipient number of member reimbursement of certain multisource Vytone • Date of birth of member prescription drugs. This price will typically cover Anusol HC suppositories • Physician’s name, license number, the acquisition of most generics but not Donnatal and specialty branded versions of the same drug. The Tigan • Physician’s phone and fax numbers products selected for inclusion on the MAC list Naldecon are commonly prescribed and dispensed and • Name of primary care physician if different have usually gone through the FDA’s review and approval process. This process assures Prior Authorization (PA) • Drug name, strength, and quantity the following requirements have been met: of medication To ensure that select medications are utilized • Days supply (duration of therapy) and The generic drug will contain the same active appropriately, Prior Authorization may be number of refills ingredient(s)