Common use of Preferred Drug List and Formulary Requirements Clause in Contracts

Preferred Drug List and Formulary Requirements. The Contractor shall maintain a preferred drug list (PDL) for the Contractor’s Hoosier Healthwise packages. The Hoosier Healthwise formulary shall support the coverage and non-coverage requirements for legend and non-legend drugs by Indiana Medicaid. More information can be found in 000 XXX 0-00-0, 405 IAC 5-24-4, 405 IAC 5-24-5 and 407 IAC 3-10-1. Prior to implementing a PDL or formulary, the Contractor shall: (i) submit the PDL or formulary to OMPP for submission to the Drug Utilization and Review (DUR) Board; and (ii) receive approval from OMPP in accordance with IC 00-00-00-00. At least thirty-five (35) days before the intended implementation date of the PDL and formulary, the Contractor shall submit its proposed PDL and formulary to OMPP. The OMPP shall submit the PDL and formulary to the Drug Utilization Review (DUR) Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL and formulary. The DUR Board will provide a recommendation regarding approval of the PDL and formulary in accordance with the terms of IC 00-00-00-00. OMPP will approve, disapprove or modify the PDL and/or formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL and/or formulary. In accordance with IC 00-00-00-00, prior to removing one (1) or more drugs from the PDL and/or formulary or otherwise placing new PA criteria on one

Preferred Drug List and Formulary Requirements. The Contractor shall maintain a preferred drug list (PDL) for the Contractor’s Hoosier Healthwise packages. The Hoosier Healthwise formulary shall support the coverage and non-coverage requirements for legend and non-legend drugs by Indiana Medicaid. More information can be found in 000 XXX 0-00-0, 405 IAC 5-24-4, 405 IAC 5-24-5 and 407 IAC 3-10-1. In accordance with CMS-2390-F, the Contractor shall demonstrate prescription drug coverage consistent with the amount, duration, and scope of the fee-for-service program. The Contractor shall engage with the State process to develop universal medically necessary prior authorization criteria for IHCP. The Contractor shall implement the universal IHCP criteria into their program and may not utilize more restrictive criteria. Prior to implementing a PDL or formulary, the Contractor shall: (i) submit the PDL or formulary to OMPP for submission to the Drug Utilization and Review (DUR) Board; and (ii) receive approval from OMPP in accordance with IC 00-00-00-00. At least thirty-five (35) days before the intended implementation date of the PDL and formulary, the Contractor shall submit its proposed PDL and formulary to OMPP. The OMPP shall submit the PDL and formulary to the Drug Utilization Review (DUR) Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL and formulary. The DUR Board will provide a recommendation regarding approval of the PDL and formulary in accordance with the terms of IC 00-00-00-00. OMPP will approve, disapprove or modify the PDL and/or formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL and/or formulary. In accordance with IC 00-00-00-00, prior to removing one (1) or more drugs from the PDL and/or formulary or otherwise placing new PA criteria on one.

Preferred Drug List and Formulary Requirements. The Contractor shall maintain a preferred drug list (PDL) for the Contractor’s Hoosier Healthwise packages. The Hoosier Healthwise formulary shall support the coverage and non-coverage requirements for legend and non-legend drugs by Indiana Medicaid. More information can be found in 000 XXX 0-00-0, 405 IAC 5-24-4, 405 IAC 5-24-5 and 407 IAC 3-10-1. Prior to implementing a PDL or formulary, the Contractor shall: (i) submit the PDL or formulary to OMPP for submission to the Drug Utilization and Review (DUR) Board; and (ii) receive approval from OMPP in accordance with IC 00-00-00-00. At least thirty-five (35) days before the intended implementation date of the PDL and formulary, the Contractor shall submit its proposed PDL and formulary to OMPP. The OMPP shall submit the PDL and formulary to the Drug Utilization Review (DUR) Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL and formulary. The DUR Board will provide a recommendation regarding approval of the PDL and formulary in accordance with the terms of IC 00-00-00-00. OMPP will approve, disapprove or modify the PDL and/or formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL and/or formulary. In accordance with IC 00-00-00-00, prior to removing one (1) or more drugs from the PDL and/or formulary or otherwise placing new PA criteria on oneone (1) or more drugs, the Contractor shall submit the proposed change to the OMPP which shall forward the proposal to the DUR Board. Such changes shall be submitted at least thirty-five

Preferred Drug List and Formulary Requirements. The Contractor shall maintain a preferred drug list (PDL) for the Contractor’s Hoosier Healthwise packages. The Hoosier Healthwise formulary shall support the coverage and non-coverage requirements for legend and non-legend drugs by Indiana Medicaid. More information can be found in 000 XXX 0405 IAC 5-0024-03, 405 IAC 5-24-4, 405 IAC 5-24-5 and 407 IAC 3-10-1. Prior to implementing a PDL or formulary, the Contractor shall: (i) submit the PDL or formulary to OMPP for submission to the Drug Utilization and Review (DUR) Board; and (ii) receive approval from OMPP in accordance with IC 00-00-00-00. At least thirty-five (35) days before the intended implementation date of the PDL and formulary, the Contractor shall submit its proposed PDL and formulary to OMPP. The OMPP shall submit the PDL and formulary to the Drug Utilization Review (DUR) Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL and formulary. The DUR Board will provide a recommendation regarding approval of the PDL and formulary in accordance with the terms of IC 00-00-00-00. OMPP will approve, disapprove or modify the PDL and/or formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL and/or formulary. In accordance with IC 00-00-00-00, prior to removing one (1) or more drugs from the PDL and/or formulary or otherwise placing new PA criteria on one

Preferred Drug List and Formulary Requirements. The Contractor shall maintain a distinct preferred drug list (PDL) for the Contractor’s Hoosier Healthwise packages. The Hoosier Healthwise formulary shall support the coverage and non-coverage requirements for legend and non-legend drugs by Indiana Medicaid. More information can be found in 000 XXX 0-00-0, 405 IAC 5-24-4, 405 IAC 5-24-5 and 407 IAC 3-10-1. Prior to implementing a PDL or formulary, the Contractor shall: (i) submit the PDL or formulary to OMPP for submission to the Drug Utilization and Review (DUR) Board; and (ii) receive approval from OMPP in accordance with IC 00-00-00-00. At least thirtyforty-five (3545) days before the intended implementation date of the PDL and formulary, the Contractor shall submit its proposed PDL and formulary to OMPP. The OMPP shall submit the PDL and formulary to the Drug Utilization Review (DUR) Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL and formulary. The DUR Board will provide a recommendation regarding approval of the PDL and formulary in accordance with the terms of IC 00-00-00-00. OMPP will approve, disapprove or modify the PDL and/or formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL and/or formulary. In accordance with IC 00-00-00-00, prior to removing one (1) or more drugs from the PDL and/or formulary or otherwise placing new PA criteria restrictions on oneone (1) or more drugs, the Contractor shall submit the proposed change to the OMPP which shall forward the proposal to the DUR Board. Such changes shall be submitted at least forty-five (45) calendar days in advance of the proposed change. The Contractor shall also meet with OMPP staff, as directed by OMPP, to answer questions about the clinical rationale for the proposed change. The DUR Board will provide a recommendation regarding approval of the proposed change to the PDL and/or formulary in accordance with the terms of IC 00-00-00-00. OMPP will approve, disapprove or modify the PDL and/or formulary based on the DUR Board’s recommendation. The Contractor is not required to seek approval from the State in order to add a drug to the PDL or formulary; however, the Contractor shall notify the OMPP of any addition to the PDL and/or formulary within thirty (30) days after making the addition. The PDL and formulary shall be made readily available to providers in the Contractor’s network and to members. The PDL and formulary shall be updated to reflect all changes in the status of a drug or addition of new drugs. The Contractor shall also support e- Prescribing technologies to communicate the PDL and formulary to prescribers through electronic medical records (EMRs) and e-Prescribing applications. See Section 3.4.5 for additional requirements on e-Prescribing. Consistent with the requirements of Section 5.7, the Contractor shall develop provider education and outreach aimed at educating providers about the Hoosier Healthwise PDL and formulary as well as the utilization of e-Prescribing technologies to ensure appropriate prescribing for members based on the member’s benefit plan. The Contractor must consider, in its proposal, using the State’s PDL for all of its pharmacy plan benefits and to contract with the State’s PBM contractor for all pharmacy claims processing. The Contractor shall be permitted to utilize the work of the Therapeutics Committee and DUR Board in maintaining the State’s PDL for the Contractor’s Hoosier Healthwise State Plan benefits. Assure that non-drug products approved for use in compounding are not subject to rebating manufacturer requirements.