Current through September 21, 2024
(a) A service may
be placed on the Preferred Drug List if the service:
(i) Is a covered service;
(ii) Is cost-effective; and
(iii) Has been reviewed by the P&T
Committee.
(b) Services
that require listing on the Preferred Drug List.
(i) Review by the Pharmacy and Therapeutics
(P&T) Committee. The P&T Committee shall review services of the same
therapeutic class in order to determine if one (1) or more services are more
clinically effective than others in the same class, or if all services in the
class are determined to be clinically equivalent. In reviewing therapeutic
classes, the P&T Committee shall consider the clinical efficacy of the
services as determined by consensus of the P&T Committee utilizing:
(A) Evidence-based research
reports;
(B) Peer-reviewed clinical
literature; and
(C) Nationally
recognized practice standards.
(ii) In order to solicit comments, the
P&T Committee may provide notice to interested parties of services which
are under consideration for designation on the Preferred Drug List and the
criteria applied to such services.
(iii) Recommendation to the Department. The
P&T Committee shall make a recommendation to the Department about whether
one (1) or more services are more clinically safe or effective than others in
the same therapeutic class.
(iv)
Consideration of recommendation. The Department may consider the recommendation
of the P&T Committee in determining whether to assign services to the
Preferred Drug List. The Department may also consider information from CMS and
other sources of clinical information which it deems relevant to the
determination. The Department shall not be bound by the recommendations of the
P&T Committee, but the Department shall not assign services to the
Preferred Drug List until it has received and considered the P&T
Committee's recommendation.
(c) Once the Department has chosen services
for the Preferred Drug List for a therapeutic class, the Department will refer
all non-preferred services to the P&T Committee for recommendations on
prior authorization, and the criteria to be used for those services.
(i) As new drugs in a therapeutic class are
introduced, the Department may change or update prior authorization criteria to
include the new services until the P&T Committee can make recommendations
to the Department in regard to the services.
(ii) In the event the Department changes the
preferred service for a therapeutic class, the Department may ask the P&T
Committee to review and update the prior authorization criteria based upon
changes to the non-preferred services.
(d) The Department may make changes to the
Preferred Drug List for a therapeutic class based upon recommendations from the
P&T Committee or changes in pricing.
(e) Notice of services on the Preferred Drug
List. If additional services are designated pursuant to this section, the
Department shall disseminate notice of the additional services on the Preferred
Drug List to providers through bulletins, manuals, or a designated
website.
(f) Procedure for
requesting other service coverage. A provider seeking reimbursement for
services not listed as the Preferred Drug in its therapeutic class may request
prior authorization pursuant to the procedures as defined in Section
13.
