Section
3.16 Medication Formulary
3.16.1
Introduction
3.16.2 References
3.16.3 Scope
3.16.4 Did you know…?
3.16.5 Definitions
3.16.6 Objectives
3.16.7 Procedures
3.16.7-A. How is the formulary used to access
medications?
3.16.7-B. Prior authorization
3.16.7-C. How can I have input?
3.16.1
Introduction
This section is only applicable to behavioral health providers
contracted with a Tribal or Regional Behavioral Health Authority (T/RBHA.)
To ensure the availability of safe, cost-effective and efficacious
medications, Arizona Department of Health Services/Division of
Behavioral Health Services (ADHS/DBHS) maintains a formulary of medications that
T/RBHAs,
at a minimum, must have on their formularies. ADHS/DBHS may add
or delete medications from the minimum formulary based on factors such
as obsolescence, toxicity, and substitution of superior products
or newer treatment options. Eligible persons must have access to
all covered laboratory, radiology, cardiology and other medical
testing services.
Effective January 1, 2006, Medicare eligible behavioral health
recipients, including persons who are dually eligible for Medicare
(Title XVIII) and Medicaid (Title XIX/XXI), began receiving Medicare
Part D prescription drug benefits through Medicare Prescription Drug
Plans (PDPs) or Medicare Advantage Prescription Drug Plans (MA-PDs).
Prescription drug coverage for Medicare eligible behavioral health
recipients enrolled in Part D is based on Part D plans' formularies.
Benzodiazepines, barbiturates and over the counter medications are
excluded under Part D and are Title XIX/XXI reimbursable for Title
XIX/XXI eligible persons. There may be an occasion when a behavioral
health recipient's prescribed drug is not available through his/her
Part D plan's formulary. This is considered a non-covered Part D
drug. Persons determined to have a Serious Mental Illness (SMI),
both dual eligibles and Non-Title XIX/XXI Medicare eligible persons,
must maintain access to needed behavioral health medications as
required by 9 A.A.C. 21. T/RBHAs and/or behavioral health providers
may assist behavioral health recipients with requesting an exception
from the Part D plan to acquire a drug not on a Part D plan's
formulary. When Part D plans do not grant an exception and when Part
D covered drugs are not on a Part D plan's formulary, T/RBHAs may
use state funds to cover the medications. Use of state funds to
cover Part D non-covered drugs, for behavioral health recipients
other than persons determined to have a SMI, will be based on
available funding as determined by the T/RBHA. (See
Section 3.21, Service
Prioritization for Non-Title XIX/XXI Funding).
3.16.2
References
The following citations can serve as additional resources for this
content area:
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3.16.3
Scope
To whom does this apply?
Medications are available through the
T/RBHAs to:
- All Title XIX and Title XXI
eligible persons (excluding dual eligible persons);
- All Medicare eligible persons who
are prescribed benzodiazepines, barbiturates and/or over the
counter drugs;
- All persons determined to have
Serious Mental Illness; and
- All other persons, based on
available funding in accordance with
Section 3.21, Service
Prioritization for Non-Title XIX/XXI Funding, or as
determined by the T/RBHA to have a medication benefit. Only
medications on the T/RBHA formulary may be covered.
3.16.4
Did you know?
- That, at
a minimum, the T/RBHA’s formulary must include all medications
on the ADHS/DBHS medication formulary, however, T/RBHAs may choose
to maintain a more comprehensive formulary of covered medications.
- That the
updated ADHS/DBHS medication formulary is posted on the ADHS/DBHS website
at http://www.hs.state.az.us/bhs/md/medlist.pdf.
Updated information concerning covered medical testing services
is also posted on the ADHS/DBHS website as part of the ADHS/DBHS
Covered Services Guide (http://www.hs.state.az.us/bhs/covserv.htm).
- Each Medicare Prescription Drug
Plan (PDP) and Medicare Advantage plan (MA-PD or MA-PD/Special
Needs Plan) establishes its own formulary. Formularies are based
on the Medicare Modernization Act Final Guidelines - Formularies
issued by the Centers for Medicare and Medicaid Services (CMS).
Each Part D plan’s formulary can be reviewed through
www.medicare.gov.
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3.16.5
Definitions
ADHS/DBHS
Medication List
Behavioral Health Medical Practitioner
Dual
Eligible
Formulary
Medicare Advantage Prescription Drug Plan (MA-PD)
Prescription Drug Plan (PDP)
Prior
Authorization
3.16.6
Objectives
To provide persons access to safe, cost-effective and efficacious
medications.
3.16.7
Procedures
3.16.7-A.
How is the formulary used to access medications?
Behavioral health providers contracted with a Tribal RBHA must reference
the AHCCCS Medication Formulary to determine what medications are available.
Formulary
Medications
The Gila River RBHA does not currently maintain a formulary of psychiatric
medications. However, all medications included on the ADHS/DBHS
medication formulary are available to Gila River RBHA enrolled members
through Indian Health Services. In the future, the Gila River RBHA
intends to add a community based pharmacy to the provider network
and to establish a medication formulary. Formulary medications
will be accessed through Medicare Part D plans for Medicare eligible
persons. A person receiving medication(s) has the right to appeal a T/RBHA Formulary change that affects his/her access to medication(s) by speaking with the pharmacy/Indian Health Services.
Non-Formulary
Medications
The Gila River RBHA does not currently maintain a formulary of psychiatric
medications. Accessing non-formulary medications will be
contingent on policies set forth by each Part D plan. If a
prescription drug is not included on the recipients’ Part D plan
formulary, the T/RBHA
may provide coverage of the drug in accordance with
Section 3.21, Service
Prioritization for Non-Title XIX/XXI Funding.
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3.16.7-B:
Prior authorization
A T/RBHA may require certain medications to be prior authorized.
See section 3.14, Securing Services and Prior Authorization for
details. The Gila River RBHA does not require prior authorization
for psychiatric medications.
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3.16.7-C:
How can I have input?
Behavioral health providers can offer suggestions for adding
or deleting medications to ADHS/DBHS or their contracted T/RBHA.
Changes
to the ADHS/DBHS Medication Formulary
This section only applies to behavioral health providers contracted
with RBHAs, not Tribal RBHAs. To propose additions to or deletions
from the ADHS/DBHS medication formulary, a Behavioral Health medical
Practitioner may submit a request
to the ADHS/DBHS Medical Director:
Medical Director
Department of Health Services
Division of Behavioral Health Services
150 North 18th Avenue, Suite 200
Phoenix, AZ 85007-3238
(602) 364-4753 (office)
(602) 364-4570 (fax)
Additions:
Requests for additions must include the following information:
- Medication
requested (trade name and generic name, if applicable);
- Dosage forms,
strengths and cost of the medication requested;
- Average
daily dosage;
- Indications
for use (including pharmacological effects, therapeutic uses of
the medication and target symptoms);
- Advantages
of the medication (including any relevant research findings if
available);
- Adverse
effects reported with the medication;
- Specific
monitoring required; and
- The drugs
on the current formulary that this medication could replace.
Deletions:
A detailed summary of the reason requesting the deletion.
What happens
with my request?
The ADHS/DBHS Medical Director will bring the request to the ADHS/DBHS
Pharmacy and Therapeutics Committee for review. The ADHS/DBHS Pharmacy
and Therapeutics Committee approves or disapproves requests for
changes to the
ADHS/DBHS medication formulary.
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3.16
Medication Formulary
Last Revised: 03/15/2007
Effective: 05/15/2008 |
