SUPDL and Formulary Requirements. For purposes of this section, the “formulary” is defined as the SUPDL and “non- formulary” is defined as covered outpatient drugs not included in the SUPDL. The Contractor shall maintain formulary (i.e., SUPDL) and covered non-formulary (i.e., non-SUPDL) drug lists for the Hoosier Care Connect packages. The Contractor must use the SUPDL as its formulary and may not develop and use its own PDL for any therapeutic categories that are part of the SUPDL. The Contractor will be provided opportunities to offer feedback on the SUPDL to the State. The State shall provide the Contractor with fifteen (15) calendar days’ notice of any change to the SUPDL, except those changes resulting from a drug shortage, recall or discontinuation, and the Contractor shall have an additional fifteen (15) calendar days to implement the change, including any system change. A drug that is on the SUPDL must have the same criteria and forms as the FFS PDL even if it is reimbursed as a medical claim. The Contractor shall submit any changes to the contents of the approved non- formulary drug list and any changes to prior authorization or medical necessity criteria applied to the non-formulary drug list to OMPP at least 60 days prior to the intended implementation date. OMPP may disapprove or modify the proposed changes within 30 days of receipt. If no response is received from OMPP within 30 days, the Contractor may implement the proposed changes. The formulary and non-formulary covered drug lists shall support the coverage and non-coverage requirements for legend and non-legend drugs by Indiana Medicaid. More information can be found in 405 IAC 5-24-3, 405 IAC 5-24-4, 405 IAC 5-24-5 and 407 IAC 3-10-1. In accordance with CMS-2390-F and 42 CFR 438.210, the Contractor shall demonstrate prescription drug coverage consistent with the amount, duration, and scope of the fee-for-service program. Per 42 CFR § 423.100, prescription drug coverage means coverage of Part D drugs that is either standard prescription drug coverage or basic alternative coverage. The Contractor shall follow the SUPDL prior authorization criteria for SUPDL drug classes. Per 42 CFR § 419.81, preauthorization (or prior authorization) means the process through which a request for provisional affirmation of coverage is submitted to CMS or its contractors for review before the service is provided to the beneficiary and before the claim is submitted for processing. Per 42 CFR 438.10(i)(1)-(2), the Contractor shall make availab...
SUPDL and Formulary Requirements. For purposes of this section, the “formulary” is defined as the SUPDL and “non- formulary” is defined as covered outpatient drugs not included in the SUPDL. The Contractor shall maintain formulary (i.e., SUPDL) and covered non-formulary (i.e., non-SUPDL) drug lists for the Contractor’s Healthy Indiana Plan packages. The Contractor must use the SUPDL as its formulary and may not develop and use its own PDL for any therapeutic categories that are part of the SUPDL. The Contractor will be provided opportunities to offer feedback on the SUPDL to the State. The State shall provide the Contractor with fifteen (15) calendar days’ notice of any change to the SUPDL, except those changes resulting from a drug shortage, recall or discontinuation, and the Contractor shall have an additional fifteen (15) calendar days to implement the change, including any system change. A drug that is on the SUPDL must have the same criteria and forms as the FFS PDL even if it is reimbursed as a medical claim.
