DCS Comprehensive Health Plan

Prescription Medication Services

Statement/Purpose

The purpose of this policy is to outline medication/prescription coverage requirements and limitations of the DCS CHP pharmacy benefit and other medication specific policies.

Definitions

AHCCCS Pharmacy and Therapeutics Committee (P&T): The advisory committee to AHCCCS, which is responsible for developing, managing, updating, and administering the AHCCCS Drug List. The P&T Committee is primarily comprised of physicians, pharmacists, nurses, other health care professionals and community members.

Grandfathering of Non-Preferred Drugs: Grandfathering of non-preferred drugs refers to the continued authorization of non-preferred drugs for members who are currently utilizing non-preferred drugs without having completed step therapy of the preferred drug(s) or meeting the prior authorization guidelines on the AHCCCS Preferred Drug List (PDL), as appropriate.

Non-Preferred Drug: A medication that is not listed on the AHCCCS Drug List. Non-Preferred drugs require prior authorization.

Preferred Drug: A medication that has been clinically reviewed and approved by the AHCCCS P&T Committee for inclusion on the AHCCCS Drug List as a preferred drug due to its proven clinical efficacy and cost effectiveness.

Step Therapy: The practice of initiating drug therapy for a medical condition with the most cost-effective and safe drug, and stepping up through a sequence of alternative drug therapies if the preceding treatment option fails.

Policy

DCS CHP pharmacy benefit covers medically necessary, cost-effective, and federally and state reimbursable medications for members as prescribed and/or administered by a physician, physician’s assistant, nurse practitioner, dentist, or other AHCCCS registered practitioner and dispensed by an AHCCCS registered licensed pharmacy pursuant to 9 A.A.C. 22 Article 2, 9 A.A.C. 28 Article 2, and 9 A.A.C. 31 Article 2.

The DCS CHP pharmacy benefit is implemented through a contracted MCO and their affiliated Pharmacy Benefit Manager (PBM).

DCS CHP utilizes the AHCCCS Prescription Drug List (PDL). The PDL is updated when changes occur, and as needed, through the AHCCCS Pharmacy and Therapeutics Committee. DCS CHP’s pharmacy benefit requires the PBM to implement the PDL adds, deletes, and updates and requires the PBM to implement edits at the point-of-sale (POS) that communicate back to the pharmacy the preferred drug(s) of a therapeutic class whenever a claim is submitted for a non-preferred drug.

DCS CHP’s pharmacy benefit maintains a Prior Authorization (PA) process for formulary medication that require Prior Authorization, and to make medically necessary non-formulary drugs, including over the counter medications (OTCs) available to members. All federally and state reimbursable drugs that are not listed on the PDL are available through the PA process. Drugs that are not on the federal rebate list are not covered under the AHCCCS program.

DCS CHP pharmacy benefit approves preferred drugs listed on the PDL before approving a non-preferred drug unless:

• The member has previously completed step therapy using the preferred drug(s), or

• The member’s prescribing clinician supports the medical necessity of the non-preferred drug over the preferred drug for the particular member.

Criteria for medication-related decisions on coverage and medical necessity are based on medical necessity documentation in addition to scientific evidence and standards of practice including, but not limited to, peer-reviewed medical literature, research data, and/or published practice guidelines.

DCS CHP pharmacy benefit requires the use of a generic equivalent drug whenever one is available and follows the PDL except in the following circumstances:

• Wlcdhen the cost of the generic drug has an overall negative financial impact to the state (this is indicated by the identification of federal and supplemental rebates); or

• If the negotiated rate of the brand name drug is equal or less than the cost of the generic drug.

All considerations for generic and biosimilar substitutions adhere to Arizona State Board of Pharmacy rules and regulations. DCS CHP pharmacy benefit does not transition to a biosimilar drug until AHCCCS has determined that the biosimilar drug is overall more cost-effective to the state than the continued use of the brand name drug.

DCS CHP pharmacy benefit implements and monitors at a minimum, the following point-of-sale DUR edits used by network pharmacies and the PBM electronic DUR system:

• Preferred and non-preferred federally and state reimbursable drugs prior to dispensing,

• Drug-drug interactions,

• Excessive doses,

• High and suboptimal dosages,

• Over and underutilization,

• Drug-pregnancy precautions,

• Drug-disease interactions,

• Duplicate therapy, and

• Drug-age precautions.

DCS CHP pharmacy benefit implements pharmacy/provider restrictions through the PBM for members who have excessive use of prescription-controlled substances and drugs of abuse potential, as applicable. If members are restricted to a specific prescribing provider or pharmacy, they are provided written Notice of Provider Restriction.

DCS CHP’s pharmacy benefit and the PBM implement an Opioid utilization program which sets point of sale limits on the quantity and duration related to short and long acting opioids medications in compliance with the Arizona State Opioid guidelines.

DCS CHP’s pharmacy benefit and the PBM conduct education and focused interventions with providers, pharmacies, and members about drug utilization and profile results in order to improve safety, prescribing practices and therapeutic outcomes. Interventions are based on utilization patterns observed through review of the pharmaceutical reports and may include educational material in provider newsletter. DCS CHP and its contracted MCO educates prescribers on their responsibility to report suspicion of drug diversion and the responsible agencies to notify according to state and federal guidelines.

DCS CHP’s pharmacy benefit and the PBM follow a medication recall process to identify members that received medications or devices that were recalled, with subsequent outreach and action as needed.

DCS CHP’s pharmacy benefit and the PBM have administrative guidelines in place to allow overrides in place for emergency fills in the event of new placement; loss or damage to medication or school supplies; medications taken incorrectly and vacation fills. There are safeguards in place for members with restrictions to exclusive pharmacy and/or providers, so as to maintain their access to services and in the event of an emergency.

Procedure

Authorizations

DCS CHP pharmacy benefit works with contracted MCO and the PBM to ensure compliance with authorization processing based on DCS CHP/AHCCCS guidelines.

DCS CHP’s pharmacy benefit authorizes and overrides medications through its contracted MCO’s PBM. The DCS CHP PA oversight procedure is implemented for reviewing medication authorizations (see DCS CHP HS-MM-04, Prior Authorization).

Utilization of preferred medications on the PDL is required unless the member completed Step Therapy or the member’s health provider supports the medical necessity of the non-preferred medication over the preferred medication for the particular member.

Medications in certain categories are reviewed through the prior authorization process. These include, but may not be limited to:

• Antidepressant medications in children under 6 years of age

• Antipsychotic medications in children under 6 years of age

• Antianxiety medications in children under 6 years of age

• Attention-deficit Hyperactivity Disorder (ADHD) medications for children under 6 years of age

• Clozapine under Age 18

• Concomitant Antidepressant Treatment

• Concomitant Antipsychotic Treatment

• Long Acting Antipsychotic Injectables Under 18 years of age

Denials for medications are reviewed by the contracted MCO’s Medical Directors and/or pharmacists and if not approvable for certain classes of medications.

Denied PA decisions are conveyed to the prescribing provider. A Notice of Adverse Benefit Determination (NOA) is issued for all denials to the member and/or custodial agency representative for the child, unless the prescriber is in agreement with the change to the preferred medication.

Timeframes for Processing Authorizations

Providers and/or members are notified of PA determinations within the standard and expedited timeframes required by AHCCCS and set forth in federal and state law and regulations. All prior authorizations for medications require a response time within 24 hours, whether that is an approval, denial, or request for more information. If additional information is needed, a final decision is rendered within 7 calendar days from the initial date of the request.

Authorization Criteria and Guidelines

DCS CHP’s pharmacy benefit applies relevant criteria and guidelines to determine medical necessity, including but not limited to:

• Food and Drug Administration (FDA) approved indications and limits;

• Published practice guidelines and treatment protocols;

• Comparative data evaluating the efficacy, type and frequency of side effects and potential drug interactions among alternative products as well as the risks, benefits and potential member outcomes;

• Drug Facts and Comparisons;

• American Hospital Formulary Service Drug Information;

• United States Pharmacopeia – Drug Information;

• DRUGDEX Information System;

• UpToDate;

• MicroMedex;

• Peer-reviewed medical literature, including randomized clinical trials, outcomes, research data and pharmacoeconomic studies; and

• Other drug reference resources or relevant national guidelines.

Emergency override procedures are in place for vacation fills, medication loss, school supplies and damaged medications and have been provided to the PBM and the contracted MCO’s customer service desk. When a member has been restricted to a specific pharmacy and/or prescriber due to overuse of opioid medications, the contracted MCO’s PBM has established parameters for an override if that pharmacy is not open or does not have the medication or the prescriber is unavailable.

Monitoring

DCS CHP pharmacy benefit utilizes prescription claim data, the Arizona State Board of Pharmacy Prescription Monitoring Program (AzPMP), for monitoring, oversight and care coordination.

DCS CHP pharmacy benefit evaluates pharmacy/prescription data on a monthly, quarterly and/or ad-hoc basis to monitor behavioral health, Specialty (e.g. Synagis), Growth Hormone, Contraceptives and Asthma medication types and verify costs and utilization. Data includes controlled substances and drugs of abuse potential, which include but are not limited to:

• Atypical Antipsychotics;

• Benzodiazepines;

• Hypnotics;

• Muscle Relaxants;

• Opioids; and

• Stimulants.

Pharmacy data is monitored to identify medications filled too soon or for maintenance medications, not filling on time; the number of prescribers and different pharmacies utilized by the member; and other data that may indicate underuse, misuse or overuse. Analysis of these reports may result in referrals for care management, provider education, formulary changes and evaluation of fraud, waste or abuse. These may be presented in the QM/PI and MM committee meetings as appropriate.

Care Management Activities Related to Pharmacy Data

Pharmacy data is utilized within the MCO’s Integrated Care Management Program to coordinate care for members as well as for specific chronic disease management processes which include but are not limited to:

• Controlled substance use evaluation to identify misuse as defined by:

  • Members who have utilized four (4) or more prescribers, and four (4) or more different abuse potential drugs and four (4) or more pharmacies in a three (3) month period;

  • Members who have received 12 or more prescriptions for atypical antipsychotics, benzodiazepines, hypnotics, muscle relaxants, opioids; and stimulants in the last 3 months; and

  • Members who have presented a forged or altered prescription to the pharmacy.

• Members who meet the parameters above may be assigned to an exclusive pharmacy in accordance with all relevant state and federal laws and regulations for up to a 12 month period and may also be assigned to a single prescriber. Exceptions include members with an active oncology diagnosis, in hospice, or in a skilled nursing facility. Members who are assigned to an exclusive pharmacy/prescriber for up to 12 months are provided notice with legal basis for the restriction, and are notified of their ability to file a written appeal and the time frames for doing so. DCS CHP’s pharmacy benefit will not implement the restriction before providing the member the 30-day notice and opportunity for a hearing.

• HIV care management and medication compliance;

• Specialty health care needs;

• Medication/Device recalls.

Operational Oversight

DCS CHP work closely with the contracted MCO and the PBM on all clinical, financial and operational issues. A quarterly P&T meeting is conducted to review that aspects of the contract with the MCO and PBM function appropriately. Issues are discussed for resolution or planning of a solution. Oversight includes but is not limited to:

• Authorization timeframes;

• Pharmacy medication costs

• PDL and POS changes to meet AHCCCS guidelines

Finance and pharmacy will review pharmacy costs no less than quarterly, and analyze the costs/spend for all medications and evaluate specialty medications, behavior health and physical health medications.

For Federally Qualified Health Centers (FQHC) and FQHC look-alike pharmacies, all drugs identified in the 340B Drug Pricing Program are required to be billed at the lesser of:

• The actual acquisition cost of the drug, or

• The 340B ceiling price (reimbursed at the lesser of the two amounts, plus a dispensing fee).

In the event that DCS CHP has a dual-eligible (Medicare/Medicaid) member, DCS CHP does not reimburse prescription claims for Barbiturates used in the treatment of epilepsy, cancer or chronic health conditions or Benzodiazepines for any condition.

Other Considerations

Deaths caused by medication poisoning/overdose or due to toxic substances are referred to the Quality Management (QM) Manager for research and review for a possible Quality of Care (QOC) concern. All suspected fraud and abuse is reported to the appropriate regulatory agency.

Marijuana is not a prescribed drug or medication. Under 42 CFR § 440.120, Marijuana does not qualify as a federally reimbursable medication. AHCCCS does not currently cover and has never covered Medical Marijuana as a medical or pharmacy benefit.

Tobacco cessation products are covered by AHCCCS and are known to be reliable in increasing long-term smoking abstinence rates in adults. The maximum supply is a 12 week supply in a six- month time period. Prior authorization is required for members under 18 years of age.

General vaccine administration for children in foster care is not covered through the pharmacy and should be administered by the child’s Primary Care Provider (PCP) in their Medical Home with appropriate anticipatory guidance, monitoring and use of the Vaccine for Children (VFC) supply. As of September 2020, children 3 years and up were eligible to receive the flu vaccine at a network pharmacy.

Reporting

Internal reporting:

DCS CHP monitors the pharmacy data weekly, monthly and quarterly as needed and is not limited to:

• Number of claims;

• Cost of claims;

• Specialty medications;

• Asthma medications;

• Preferred drug compliance; and

• Compounds

• Antipsychotic prescribing for children

DCS CHP conducts internal quarterly Pharmacy and Therapeutics Meeting reporting:

• Formulary Oversight

• Prior Authorization

• Medication Recalls

• Flu vaccine

• RSV Prophylaxis

• Fraud, Waste, and Abuse

• Pharmacy Service Overview

• Pharmacy Benefit Manager Quarterly Reports

• Drug Utilization Review

• Educational Outreach Program

External reporting:

DCS CHP provides a Restriction Report to AHCCCS quarterly that includes the number of members who are restricted to using a specific pharmacy or prescriber/provider due to excessive use of prescription medications (narcotics and non-narcotics).

Performance measures by Quality Management (QM) Manager including

• Asthma Medication Ratio

• Contraceptive Care – All Women Ages 15 to 20