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 HIP program. The HIP formulary shall support the coverage and non-coverage requirements for legend drugs by Indiana Medicaid, found in 405 IAC 5-24-3. 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. While the underlying drug formulary for the HIP Plus and the HIP Basic plans will be identical, additional pharmacy services will differ between the plans in order to align the benefits with the overall program goals aimed at encouraging member participation in HIP Plus. Therefore, the HIP Basic pharmacy benefit may have more restrictions than the HIP plus benefit, such as limiting prescription supplies to 30 days. Also, prescriptions obtained by a HIP Basic or HIP State Plan Basic member that are not otherwise exempt on the basis of being preventive, family planning, or maternity, are subject to the copayment amounts set forth in Section 4.1.2. Copayments assessed to the HIP Basic or HIP State Plan Basic member at the point of sale may not exceed the total cost of the drug. Similarly, the HIP Plus pharmacy benefit shall provide additional enhanced pharmacy services including the following: (i) ninety (90) day prescription supplies of routine maintenance medications, when requested by the member; (ii) mail order pharmacy benefit;

Preferred Drug List and Formulary Requirements. The Contractor shall maintain a distinct preferred drug list (PDL) for the Contractor’s HIP programState Plan package, as well as one (1) distinct formulary applicable to the Contractor’s HIP Plus and HIP Basic packages. In addition, the Contractor shall provide a proposal which considers a common or “unified” preferred drug list (PDL) for the pharmacy benefit. The HIP formulary shall support the coverage and non-coverage requirements for legend drugs by Indiana Medicaid, found in 405 IAC 5-24-3. In accordance with CMS- 2390-FAlternatively, the Contractor shall demonstrate contractor may establish a HIP formulary that ensures the prescription drug coverage consistent with benefit covers at least the amountsame level of services as the base benchmark pharmacy benefit, durationincluding one drug in every category and class or the number of drugs covered in each category and class as the base benchmark, and scope of the fee-for-service programwhichever is greater. The Contractor contractor shall engage with the State process provide at least 60-days notice prior 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 criteriaimplementing an alternate formulary process. While the underlying drug formulary for the HIP Plus and the HIP Basic plans will be identical, additional pharmacy services will differ between the plans in order to align the benefits with the overall program goals aimed at encouraging member participation in HIP Plus. Therefore, the HIP Basic pharmacy benefit may have more restrictions than the HIP plus benefit, such as offering members access to fewer brand name drugs without either step therapy or prior authorization requirements, and limiting prescription supplies to 30 days. Also, prescriptions obtained by a HIP Basic or HIP State Plan Basic member that are not otherwise exempt on the basis of being preventive, family planning, or maternity, are subject to the copayment amounts set forth in Section 4.1.2. Copayments assessed to the HIP Basic or HIP State Plan Basic member at the point of sale may not exceed the total cost of the drug. Similarly, the HIP Plus pharmacy benefit shall provide additional enhanced pharmacy services including the following: (i) greater access to many brand name drugs, without prior authorization requirements; (ii) ninety (90) day prescription supplies of routine maintenance medications, when requested by the member; (iiiii) mail order pharmacy benefit;; (iv) Medication Therapy Management (MTM) Services; (v) and no copayment for any filled prescription. These additional pharmacy services shall only be made available to individuals participating in HIP Plus and HIP State Plan Plus benefits. 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 forty-five (45) 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. Contractors implementing a common or “unified” PDL will participate in all aspects of Indiana Medicaid’s Therapeutics Committee deliberations. 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 12-15- 35-47, prior to removing one (1) or more drugs from the PDL and/or formulary or otherwise placing new restrictions on one (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 6.4.5 for additional requirements on e-Prescribing. Consistent with the requirements of Section 8.7, the Contractor shall develop provider education and outreach aimed at educating providers about the HIP 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 HIP State Plan benefits. Assure that non-drug products approved for use in compounding are not subject to rebating manufacturer requirements.