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CHP/HEALTHY FAMILIES PROGRAM FORMULARY

DRUG FORMULARY A drug formulary is a list of medications approved for coverage and treatment of members by the Pharmacy and Therapeutics (P&T) Committee. Drugs are selected for this list based on therapeutic effectiveness, safety and cost. The formulary is designed to act as a guide to plan providers when prescribing medications for plan members.

PHARMACY AND THERAPEUTIC COMMITTEE The Pharmacy and Therapeutics (P&T) Committee is made up of community physicians and pharmacists which meet on a quarterly basis. Performance of P&T Committee functions for CHP is provided by the Office of Managed Care Medical Affairs Committee and the Los Angeles County Department of Health Services P&T Committee. The interactive process involving these two committees provides oversight on the usage of medications. The P&T Committee also aids in the development of guidelines for the proper use of participating plan physicians and pharmacists.

NON-FORMULARY DRUG REQUESTS If a prescribed drug is not on the formulary (non-formulary) and the doctor cannot change the drug to a formulary product, a prior authorization must be requested before the medication can be dispensed. The doctor is to contact the CHP Pharmacy Exceptions Department for evaluation during regular business hours or fax the request to the Office of Managed Care, Pharmacy Exceptions Program. Authorization for non- formulary drugs will be issued based on medical justification.

PRIOR AUTHORIZATIONS Prior Authorizations (PA) is the process to obtain medically necessary medications that are not included in the formulary. The purpose of the authorization is not to deny access to certain medications but to assess the appropriateness of treatment and determine medical necessity. Non-formulary and certain formulary drug require prior authorization. The use of these medications must meet CHP guidelines and Federal Drug Administration (FDA) approved indications. PA Drugs should be used only when formulary choices have failed, or when a contraindication to an alternative exists. Off-label use of a FDA approved formulary medication for life threatening or chronic and seriously debilitating conditions will be evaluated based on medical justification.

AFTER HOURS PROCEDURES If member eligibility verification or prior authorization procedures for pharmaceutical coverage is disabled, the pharmacy should fill the prescription for enough medication until an approval for a formulary product can be obtained. Medications dispensed on an emergency basis shall not exceed a three- (3) day or 72-hour supply. Drugs, which are not part of the pharmacy benefit and excluded by CHP (see excluded drugs), will not be covered by this procedure. The pharmacist may call for an after hours authorization at (800) 832-MEDI. At no time should a patient not receive a needed medication.

EXCLUDED DRUGS Excluded drugs are medications that are not reimbursable under the pharmacy benefit. Examples of these drugs include drugs for cosmetics purposes, lifestyle drugs, weight loss or appetite suppressants, and progesterone compounds for PMS treatment. Injectable medications, (except insulin, glucagons, and ANA kits), which in general are not covered under the pharmacy benefit but may be obtained through the physician’s office as a medical benefit. Also excluded are experimental or investigational drugs, unless accepted for use by the standards of the medical community and herbal, nutritional and dietary supplements (except for special food products or formulas to treat phenylketonuria). Newly introduced medications are generally excluded until the P&T Committee has evaluated the drug.

GENERIC DRUGS The CHP prescription benefit requires the dispensing of FDA approved bioequivalent multisource drugs whenever appropriate. If the doctor requests a specific brand medication to be dispensed, this must be indicated on the face of the prescription (DAW 1). Brand names will not be dispensed solely on patient preference. The P&T Committee recognizes that there are medications that have narrow therapeutic dosing characteristics. These medications are classified as having a Narrow Therapeutic Index (NTI). The P&T Committee discourages the use of generic substitution for drugs that are classified in this manner.

CHP/HF PROVIDER MANUAL 5/2004

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