Pharmacy Prior Authorization Criteria
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Central California Alliance for Health Pharmacy Prior Authorization Criteria March 2020 Notice of Nondiscrimination and Accessibility Discrimination is Against the Law Central California Alliance for Health (the Alliance) complies with Federal civil rights and nondiscrimination laws to make sure all members have access to its programs and services. This means that the Alliance does not exclude or treat members differently because of race, color, national origin, age, disability, or sex. The Alliance provides services, at no cost, to help members communicate with us. • Members with a disability can ask for: ○ A trained sign language interpreter, and ○ Written information in large print, audio, easy to use electronic formats and other formats. • Members whose primary language is not English can ask for: ○ A trained language interpreter, and ○ Information written in a language they can understand. If you need these services, contact the Alliance Member Services Department at 1-800-700-3874 or if you believe that the Alliance did not provide these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance in any of these ways: Phone: 1-800-700-3874 ext. 5816 Website: https://www.ccah-alliance.org/Complaints.html Fax: 1-831-430-5579 Email: [email protected] Mail: Grievance Department 1600 Green Hills Road, Suite 101 Scotts Valley, CA 95066 If you need help filing a grievance, our Member Service Representatives and Grievance Coordinators can help you. Contact the Alliance Member Services Department at 1-800-700-3874 or Grievance Department at 1-800-700-3874, ext. 5816. For the Hearing or Speech Assistance Line, call 1-800-735-2929 (TTY: Dial 7-1-1). You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights in any of these ways: Phone: 1-800-368-1019 (TTY: Dial 1-800-537-7697) Website: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Email: [email protected] Mail: U.S. Department of Health and Human Services, Office for Civil Rights 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Forms: https://www.hhs.gov/ocr/complaints/index.html November 4, 2016 LANGUAGE ASSISTANCESI LANGUAGE ASSISTANCE CONTINUED Alliance Contact Information Address Santa Cruz County Main Office Monterey County Office Merced County Office 1600 Green Hills Road, 950 East Blanco Road, 530 West 16th Street, Suite 101 Suite 101 Suite B Scotts Valley, CA 95066-4981 Salinas, CA 93901-3400 Merced, CA 95340-4710 (831) 430-5500 (831) 755-6000 (209) 381-5300 Hours: M-F, 8am-5pm Hours: M-F, 8am-5pm Hours: M-F, 8am-5pm Phone Directory Automated System (831) 430-5501 Authorizations – Pharmacy (831) 430-5507 Authorizations – Non-Pharmacy (831) 430-5506 Status Requests for Non-Pharmacy (831) 430-5511 Care Management (831) 430-5512 Claims Inquiries (831) 430-5503 EDI Support Line (831) 430-5510 Health Education (831) 430-5580 Member Services (831) 430-5505 Provider Services (831) 430-5504 Department Fax Numbers Administration (831) 430-5852 Claims (831) 430-5858 Finance (831) 430-5853 Health Services PA and RAFs (831) 430-5850 Member Services (831) 430-5856 Pharmacy Authorizations (831) 430-5851 Provider Services (831) 430-5857 Forward Central California Alliance for Health (The Alliance), with direction from the Pharmacy & Therapeutics (P&T) Committee, has developed this formulary to be used by Alliance providers and members. The Medi-Cal List of Contract Drugs has not been in use by the Alliance since January 1, 1997. The P&T committee will continue to update and revise this formulary based on quality of care considerations and sound pharmacoeconomic principles. The Alliance’s contract with the State of California requires mandatory generic substitution whenever an equivalent product is available. By Alliance policy, the only drugs not requiring mandatory generic substitution are Coumadin, Dilantin, and Lanoxin. However, clinicians may prescribe a Brand Name drug with a “do not substitute” order when there is clinical justification for doing so. In the latter case, a Prior Authorization must be submitted to the Alliance for consideration prior to dispensing the medication to an Alliance member. The Formulary is a list of medication available to Central California Alliance for Health members under their pharmacy benefit. All drugs are listed by their generics names and the most common proprietary (branded) name. In situations where an FDA- approved generic equivalent is available, brand names are listed for reference purposes only, and do no denote coverage for the brand. The same formulary is used for all Alliance members including Whole Child Members with California Children’s Service eligibility. Over-the-counter (OTC) medications are not a covered benefit for Knox-Keene line of business (LOB) including Medi-Cal Access Program, and IHSS except for loratadine, cetirizine, fexofenadine, ketotifen, prenatal vitamins, nicotine patches and gum, OTC contraceptives and diabetic supplies. Formulary Terms 5-Day Emergency Fills Emergency authorizations for Prior Authorizations outside of Central California Alliances’ normal business hours may be requested from MedImpact at (800) 788-2949. MedImpact may authorize up to a 5 day supply of medication, pending further authorization by Central California Alliance for Health. Central California Alliance for Health will also authorize a retroactive Prior Authorization allowing the pharmacy to dispense up to a 5 day supply of a non-formulary drug in an emergency situation. Central California Alliance for Health does not require that the situation meet any legal (i.e., pharmacy law) definition of “emergency” -- it is the judgment of the dispensing pharmacist that determines the need for emergency authorization in order to avoid pain, suffering, severe emotional distress, or worsening of any medical condition that could result in the need for emergency medical treatment. Brand Name Unless otherwise stated, the brand names shown in the formulary guide are non-formulary when an equivalent generic is approved by the FDA. Brand names used in this formulary guide are representative only, for ease of drug recognition by providers. Generic products must be dispensed whenever possible, as required by the Formulary Utilization Management Initiative (refer to State’s Medi-Cal program). Carve-Out Drugs (Excluded Drugs) The following drugs are covered by State Medi-Cal: 1. All antiretroviral drugs except Retrovir (zidovudine), and Videx (didanosine). 2. All antipsychotics, antimania, MAO inhibitors and antiparkinson anticholinergic drugs used for side effects. 3. Drugs to treat ED and opioid detoxification. 4. All blood factors and coagulation factors. 5. Certain drugs for the treatment of Hepatitis B. These are prescription services that are not included in the Alliances’ scope of coverage, but are covered (or covered with Prior Authorization) by the State Medi-Cal Fee-For-Service program. These drugs remain a potential benefit for eligible Alliance members through State Medi-Cal, but the Alliance is not financially responsible and all claims for these drugs (including secondary copays) must be reimbursed through the State Medi-Cal program. These drugs are non-formulary but, with the exception of ED drugs, are covered by the Alliance for the Medi-Cal Access program and IHSS. Please contact State Medi-Cal at 1-800-541-555 or go to https://learn.medi-cal.ca.gov/Resources/eTARNewsTips.aspx Formulary Terms (Continued) Code 1 Restriction Code 1 medications are formulary, but their use is limited to a specific medical condition, failure/intolerance to 1st line therapy, member’s place of residence, or other stipulated restriction(s). Although Code 1 restricted drugs do not require a Prior Authorization when the Code 1 restriction is met, pharmacy providers must maintain documentation that the drug is being dispensed according to the Code 1 restriction. Any other use of the drug is considered non- formulary and requires a Prior Authorization. To facilitate filling of a Code 1 prescription, prescribers should write the member’s diagnosis, and any other Code 1 criteria if met, on the prescription. Dollar Amount Limit Central California Alliance for Health has an online adjudication limit of $1,000 for any single claim, for most drugs. Claims submitted for more than $1,000 will require a Prior Authorization, even if on formulary. Compound prescription claims using formulary ingredients have a $100 limit, with a Prior Authorization required on claims that exceed $100. Dual Eligible Members A dual eligible member is a Medi-Cal member who is also eligible for Medicare, whether or not they are actually enrolled in Medicare. Medi-Cal is always secondary to Medicare, thus if patient is eligible for Medicare, Medicare must be billed prior to billing Central California Alliance for Health. Dual eligible individuals are required to join a Medicare prescription drug plan, and there is a process by which CMS auto-enrolls members into Medicare upon becoming eligible. However, if a member is not yet enrolled in Medicare, but is eligible for Medicare, there is a process by which pharmacies can enroll patients in Part D at Point-of-Sale (LINET program, administered by Humana). Medications that are excluded from the members Medicare plan may be submitted directly to Central California Alliance for Health. Please note that medication that are excluded from the Members Medicare may also be exempt from Medi-Cal &/or Central California Alliance for Health’s benefits. Medications that are non-formulary on member’s Part D (but not excluded) must go through the Prior Authorization procedures with the Part D plan rather than Central California Alliance for Health. Pharmacies may submit a Prior Authorization to Central California Alliance for Health for consideration of Part B copays; Central California Alliance for Health is federally prohibited from paying any Part D copays or deductibles. eCOB Electronic coordination of benefits (eCOB). The ability to transmit & adjudicate electronically (online) the portion of the primary insurance claim that is the patient’s responsibility, to the secondary insurance.