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 the Behavioral Health
Providers 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, the Arizona Department of Health Services/Division of
Behavioral Health Services (ADHS/DBHS) maintains a list 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. Title XIX/XXI eligible persons must have access to
all covered laboratory, radiology, cardiology and other medical
testing services.
Medicare eligible behavioral health
recipients, including persons who are dually eligible for Medicare
(Title XVIII) and Medicaid (Title XIX/XXI), receive 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.
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. T/RBHAs and/or behavioral health providers
must 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. Non-Title XIX/XXI funds are available but limited.
As such, each Tribal and Regional Behavioral Health Authority (T/RBHA) must implement
priorities for Non-Title XIX/XXI funded service delivery.
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 dual eligible persons who are prescribed medications
not covered through Medicare but covered through Medicaid;
- All persons determined to have
Serious Mental Illness (SMI); 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.
3.16.4
Did you know?
- 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.
- The
updated ADHS/DBHS medication formulary is posted on the ADHS/DBHS
website.
Updated information concerning covered medical testing services
is also posted on the ADHS/DBHS website as part of the
ADHS/DBHS
Covered Behavioral Health Services Guide.
- 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
http://www.medicare.gov.
- Medicare Part D prescription drug coverage is subject to change, and drugs that are
no longer excluded will be covered under Medicare, not Medicaid.
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3.16.5
Definitions
ADHS/DBHS
Medication Formulary
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?
Formulary
Medications
Formulary medications will be accessed through Medicare Part D plans for Medicare eligible
persons. The Gila River RBHA
does currently maintain a formulary of psychiatric
medications that includes those medications on the ADHS formulary as well as those additional medications selected by the Gila River psychiatric staff.
A person
receiving medication(s) has the right to appeal a T/RBHA Formulary
change or any decision that affects his/her coverage for
medication(s) by speaking with the pharmacy/Indian Health Services.
Non-Formulary
Medications
Accessing non-formulary medications for Medicare eligible persons 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
must assist the behavioral health recipient in obtaining the non-covered medication(s).
Other TRBHA enrolled behavioral health recipients who require non formulary medications should speak with their Gila River behavioral health medical practitioner about how to obtain these for their use.
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3.16.7-B:
Prior authorization
T/RBHA's must obtain approval from the ADHS/DBHS Medical Director or designee in writing prior to establishing prior authorization protocols for any medication included on the ADHS/DBHS Medication Formulary, including dosage and dispensing restrictions. If a T/RBHA or behavioral health provider requires prior authorization for medications, the requirements outlined in Section 3.14, Securing Services and Prior Authorization, Section 5.1, Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons, and Section 5.5, Notice and Appeal Requirements (SMI and Non-SMI, Non-TXIX/TXXI), must be met (see Section 3.14 Securing Services and Prior Authorization subsection 3.14.7-E.).
Gila River Behavioral Health Services does not require prior authorization for psychiatric medications.
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3.16.7-C:
How can the Behavioral Health Providers have input?
Behavioral health providers can offer suggestions for adding
or deleting medications to the ADHS/DBHS Medication Formulary or their contracted T/RBHA's
medication formulary..
Changes
to the ADHS/DBHS Medication Formulary
To propose additions or deletions
to the ADHS/DBHS Medication Formulary, a Behavioral Health Medical
Practitioner may submit a request
to the Chief ADHS/DBHS Medical Officer or designee:
Chief Medical Officer
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 corresponding costs 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 for requesting the deletion.
What happens
with my request?
The ADHS/DBHS Chief Medical Officer will bring the request to the ADHS/DBHS
Pharmacy and Therapeutics Committee for review. The ADHS/DBHS Pharmacy
and Therapeutics Committee advises the Chief Medical Officer of requests for
changes to the
ADHS/DBHS medication formulary.
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3.16
Medication Formulary
Last Revised: 03/1/2010
Effective: 03/1/2010 |
