Common use of Use of Formulary Clause in Contracts

Use of Formulary. The Contractor may use a formulary as long as the general requirements and the following minimum requirements are met: 1. The Contractor shall only exclude coverage of drugs or drug categories permitted under Section 1927(d) of the Social Security Act as amended by OBRA 1993. In addition, the Contractor shall include in its formulary, if it chooses to operate a formulary, any FDA- approved drugs that may allow for clinical improvement or are clinically advantageous for the management of a disease or condition. 2. The Contractor's formulary shall be developed by a Pharmacy and Therapeutics (P&T) Committee that shall represent the needs of all its enrollees including enrollees with special needs. Network physicians and dentists shall have the opportunity to participate in the development of the formulary and, prior to any changes to a drug formulary, to review, consider and comment on proposed changes. The formulary shall be reviewed in its entirety and updated at least annually. 3. The formulary for the DMAHS pharmacy benefit and any revision thereto shall be reviewed and approved by DMAHS prior to implementation. 4. The formulary shall include only FDA approved drug products. For each Specific Therapeutic Drug (STD) class, the selection of drugs included for each drug class shall be sufficient to ensure the availability of covered drugs with the least need for prior authorization to be initiated by providers of pharmaceutical services and include FDA approved drugs to best serve the medical needs of enrollees with special needs. In addition, the formulary shall be revised periodically to assure compliance with this requirement. 5. The Contractor shall authorize the provision of a drug not on the formulary requested by the PCP or referral provider on behalf of the enrollee if the approved prescriber certifies medical necessity for the drug to the Contractor for a determination. Medically accepted indications shall be consistent with Section 1927(k)(6) of the Social Security Act. The Contractor shall have in place a DMAHS-approved prior approval process for authorizing the dispensing of such drugs. In addition: a. Any prior approval issued by the Contractor shall take into consideration prescription refills related to the original pharmacy service. b. A formulary shall not be used to deny coverage of any Medicaid covered outpatient drug determined medically necessary through the review and appeal process. c. Prior approval may be used for covered drug products under the following conditions: i. For prescribing and dispensing medically necessary non-formulary drugs. ii. To limit drug coverage consistent with the policies of the Medicaid program. iii. To minimize potential drug over-utilization. iv. To accommodate exceptions to Medicaid drug utilization review standards related to proper maintenance drug therapy. d. Except for the use of approved generic drug substitution of brand drugs, under no circumstances shall the Contractor permit the therapeutic substitution of a prescribed drug without a prescriber's authorization. e. The Contractor shall not penalize the prescriber or enrollee, financially or otherwise, for such requests and approvals. f. Determinations shall be made within twenty-four (24) hours of receipt of all necessary information. The Contractor shall provide for a 72-hour supply of medication while awaiting a prior authorization determination. g. Denials of off-formulary requests or offering of an alternative medication shall be provided to the prescriber and/or enrollee in writing. i. An enrollee receiving a prescription drug that was on the Contractor’s formulary and subsequently removed or changed shall be permitted to continue to receive that prescription drug if requested by the enrollee and prescriber for as long as the enrollee is a Member of the Contractor’s plan. ii. All denials shall be reported to the DMAHS quarterly and include the following data: name of non-formulary drug; total number of requests; and total number of denials.

Use of Formulary. The Contractor contractor may use a formulary as long as the general requirements and the following minimum requirements are met: 1. The Contractor contractor shall only exclude coverage of drugs or drug categories permitted under Section 1927(d) of the Social Security Act as amended by OBRA 1993. In addition, the Contractor contractor shall include in its formulary, if it chooses to operate a formulary, any FDA- FDA-approved drugs that may allow for clinical improvement or are clinically advantageous for the management of a disease or condition. 2. The Contractorcontractor's formulary shall be developed by a Pharmacy and Therapeutics (P&T) Committee that shall represent the needs of all its enrollees including enrollees with special needs. Network physicians and dentists shall have the opportunity to participate in the development of the formulary and, prior to any changes to a drug formulary, to review, consider and comment on proposed changes. The formulary shall be reviewed in its entirety and updated at least annually. 3. The formulary for the DMAHS pharmacy benefit and any revision thereto shall be reviewed and approved by DMAHS prior to implementationDMAHS. 4. The formulary shall include only FDA approved drug products. For each Specific Therapeutic Drug (STD) class, the selection of drugs included for each drug class shall be sufficient to ensure the availability of covered drugs with the least need for prior authorization to be initiated by providers of pharmaceutical services and include FDA approved drugs to best serve the medical needs of enrollees with special needs. In addition, the formulary shall be revised periodically to assure compliance with this requirement. 5. The Contractor contractor shall authorize the provision of a drug not on the formulary requested by the PCP or referral provider on behalf of the enrollee if the approved prescriber certifies medical necessity for the drug to the Contractor contractor for a determination. Medically accepted indications shall be consistent with Section 1927(k)(6) of the Social Security Act. The Contractor contractor shall have in place a DMAHS-approved prior approval process for authorizing the dispensing of such drugs. In addition: a. Any prior approval issued by the Contractor contractor shall take into consideration prescription refills related to the original pharmacy service. b. A formulary shall not be used to deny coverage of any Medicaid covered outpatient drug determined medically necessary through the review and appeal process. The prior approval process shall be used to ensure drug coverage consistent with the policies of the New Jersey Medicaid program. c. Prior approval may be used for covered drug products under the following conditions: i. For prescribing and dispensing medically necessary non-formulary drugs. ii. To limit drug coverage consistent with the policies of the Medicaid program. iii. To minimize potential drug over-utilization. iv. To accommodate exceptions to Medicaid drug utilization review standards related to proper maintenance drug therapy. d. Except for the use of approved generic drug substitution of brand drugs, under no circumstances shall the Contractor contractor permit the therapeutic substitution of a prescribed drug without a prescriber's authorization. e. The Contractor contractor shall not penalize the prescriber or enrollee, financially or otherwise, for such requests and approvals. f. Determinations shall be made within twenty-four (24) hours of receipt of all necessary information. The Contractor shall provide for a 72A seventy-hour two (72)-hour supply of medication while awaiting a shall be permitted without prior authorization determinationin emergency situations or if a determination has not been made within the required timeframe. g. Denials of off-formulary requests or offering of an alternative medication shall be provided to the prescriber and/or enrollee in writing. i. An enrollee receiving a prescription drug that was on the Contractor’s formulary and subsequently removed or changed shall be permitted to continue to receive that prescription drug if requested by the enrollee and prescriber for as long as the enrollee is a Member of the Contractor’s plan. ii. All denials shall be reported to the DMAHS quarterly quarterly. 6. The contractor shall publish and include distribute hard copy or on-line, at least annually, its current formulary (if the following data: contractor uses a formulary) to all prescribing providers and pharmacists. Updates to the formulary shall be distributed in all formats within sixty (60) days of the changes. 7. If the formulary includes generic equivalents, the contractor shall provide for a brand name exception process for prescribers to use when medically necessary. 8. The contractor shall establish and maintain a procedure, approved by DMAHS, for internal review and resolution of non-formulary drug; total number complaints, such as timely access and coverage issues, drug utilization review, and claim management based on standards of requests; and total number of denialsdrug utilization review.

Use of Formulary. The Contractor contractor may use a formulary as long as the general requirements and the following minimum requirements are met: 1. The Contractor contractor shall only exclude coverage of drugs or drug categories permitted under Section 1927(d) of the Social Security Act as amended by OBRA 1993. In addition, the Contractor contractor shall include in its formulary, if it chooses to operate a formulary, any FDA- FDA-approved drugs that may allow for clinical improvement or are clinically advantageous for the management of a disease or condition. 2. The Contractorcontractor's formulary shall be developed by a Pharmacy and Therapeutics (P&T) Committee that shall represent the needs of all its enrollees including enrollees with special needs. Network physicians and dentists shall have the opportunity to participate in the development of the formulary and, prior to any changes to a drug formulary, to review, consider and comment on proposed changes. The formulary shall be reviewed in its entirety and updated at least annually. 3. The formulary for the DMAHS pharmacy benefit and any revision thereto shall be reviewed and approved by DMAHS prior to implementationDMAHS. 4. The formulary shall include only FDA approved drug products. For each Specific Therapeutic Drug (STD) class, the selection of drugs included for each drug class shall be sufficient to ensure the availability of covered drugs with the least need for prior authorization to be initiated by providers of pharmaceutical services and include FDA approved drugs to best serve the medical needs of enrollees with special needs. In addition, the formulary shall be revised periodically to assure compliance with this requirement. 5. The Contractor contractor shall authorize the provision of a drug not on the formulary requested by the PCP or referral provider on behalf of the enrollee if the approved prescriber certifies medical necessity for the drug to the Contractor contractor for a determination. Medically accepted indications shall be consistent with Section 1927(k)(6) of the Social Security Act. The Contractor contractor shall have in place a DMAHS-approved prior approval process for authorizing the dispensing of such drugs. In addition: a. Any prior approval issued by the Contractor contractor shall take into consideration prescription refills related to the original pharmacy service. b. A formulary shall not be used to deny coverage of any Medicaid covered outpatient drug determined medically necessary through the review and appeal process. c. Prior approval may be used for covered drug products under the following conditions: i. For prescribing and dispensing medically necessary non-formulary drugs. ii. To limit drug coverage consistent with the policies of the Medicaid program. iii. To minimize potential drug over-utilization. iv. To accommodate exceptions to Medicaid drug utilization review standards related to proper maintenance drug therapy. d. Except for the use of approved generic drug substitution of brand drugs, under no circumstances shall the Contractor permit the therapeutic substitution of a prescribed drug without a prescriber's authorization. e. The Contractor shall not penalize the prescriber or enrollee, financially or otherwise, for such requests and approvals. f. Determinations shall be made within twenty-four (24) hours of receipt of all necessary information. The Contractor shall provide for a 72-hour supply of medication while awaiting a prior authorization determination. g. Denials of off-formulary requests or offering of an alternative medication shall be provided to the prescriber and/or enrollee in writing. i. An enrollee receiving a prescription drug that was on the Contractor’s formulary and subsequently removed or changed shall be permitted to continue to receive that prescription drug if requested by the enrollee and prescriber for as long as the enrollee is a Member of the Contractor’s plan. ii. All denials shall be reported to the DMAHS quarterly and include the following data: name of non-formulary drug; total number of requests; and total number of denials.

Use of Formulary. The Contractor may use a formulary as long as the general requirements and the following minimum requirements are met: 1. The Contractor shall only exclude coverage of drugs or drug categories permitted under Section 1927(d) of the Social Security Act as amended by OBRA 1993. In addition, the Contractor shall include in its formulary, if it chooses to operate a formulary, any FDA- approved drugs that may allow for clinical improvement or are clinically advantageous for the management of a disease or condition. 2. The Contractor's formulary shall be developed by a Pharmacy and Therapeutics (P&T) Committee that shall represent the needs of all its enrollees including enrollees with special needs. Network physicians and dentists shall have the opportunity to participate in the development of the formulary and, prior to any changes to a drug formulary, to review, consider and comment on proposed changes. The formulary shall be reviewed in its entirety and updated at least annually. 3. The formulary for the DMAHS pharmacy benefit and any revision thereto shall be reviewed and approved by DMAHS prior to implementation. 4. The formulary shall include only FDA approved drug products. For each Specific Therapeutic Drug (STD) class, the selection of drugs included for each drug class shall be sufficient to ensure the availability of covered drugs with the least need for prior authorization to be initiated by providers of pharmaceutical services and include FDA approved drugs to best serve the medical needs of enrollees with special needs. In addition, the formulary shall be revised periodically to assure compliance with this requirement. 5. The In accordance with section 1927(d)(5) of the SSA, the Contractor shall authorize the provision of a drug not on the formulary requested by the PCP or referral provider on behalf of the enrollee if the approved prescriber certifies medical necessity for the drug to the Contractor for a determination. Medically accepted indications shall be consistent with Section 1927(k)(6) of the Social Security Act. The Contractor shall have in place a DMAHS-approved prior approval process for authorizing the dispensing of such drugs. In addition: a. Any prior approval issued by the Contractor shall take into consideration prescription refills related to the original pharmacy service. b. A formulary shall not be used to deny coverage of any Medicaid covered outpatient drug determined medically necessary through the review and appeal process. c. Prior approval may be used for covered drug products under the following conditions: i. For prescribing and dispensing medically necessary non-formulary drugs. ii. To limit drug coverage consistent with the policies of the Medicaid program. iii. To minimize potential drug over-utilization. iv. To accommodate exceptions to Medicaid drug utilization review standards related to proper maintenance drug therapy. d. Except for the use of approved generic drug substitution of brand drugs, under no circumstances shall the Contractor permit the therapeutic substitution of a prescribed drug without a prescriber's authorization. e. The Contractor shall not penalize the prescriber or enrollee, financially or otherwise, for such requests and approvals. f. Determinations shall be made within twenty-four (24) hours of receipt of all necessary information. The Contractor shall provide for a 72-hour supply of medication while awaiting a prior authorization determination. g. Denials of off-formulary requests or offering of an alternative medication shall be provided to the prescriber and/or enrollee in writing. i. An enrollee receiving a prescription drug that was on the Contractor’s formulary and subsequently removed or changed shall be permitted to continue to receive that prescription drug if requested by the enrollee and prescriber for as long as the enrollee is a Member of the Contractor’s plan. ii. All denials shall be reported to the DMAHS quarterly and include the following data: name of non-formulary drug; total number of requests; and total number of denials.to