CurrentCHRISTUS Health Plan Individual & Family PlanPolicy MC7746

Pharmaceutical Management Procedures

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This policy governs formulary management, prior authorization, step therapy, quantity limits, specialty pharmacy requirements, generic and preferred-brand interchange, opioid limits, and medication coverage exceptions for CHRISTUS Health Plan Individual & Family Plan members. It primarily applies to outpatient prescription medications obtained through participating pharmacies.

Policy Summary

PayerCHRISTUS Health Plan Individual & Family Plan

PolicyPharmaceutical Management Procedures

Policy CodePolicy MC7746

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization before requesting coverage for medications designated as requiring prior approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 MME/dayMaximum opioid quantity before utilization-management criteria apply

7 daysMaximum first-fill duration for opioid-naive members

Preferred specialty pharmacyRequired dispensing channel for specialty medications

844.280.5833

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CurrentCHRISTUS Health Plan Individual & Family PlanPolicy MC7746

Pharmaceutical Management Procedures

Customize your policy alerts

Sign up for christushealthplanoftexasandlousiana Policy MC7746 alerts

Get alerted when Policy MC7746 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerCHRISTUS Health Plan Individual & Family Plan

PolicyPharmaceutical Management Procedures

Policy CodePolicy MC7746

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization before requesting coverage for medications designated as requiring prior approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 MME/dayMaximum opioid quantity before utilization-management criteria apply

7 daysMaximum first-fill duration for opioid-naive members

Preferred specialty pharmacyRequired dispensing channel for specialty medications

844.280.5833

Prior authorization and medication coverage exception hotline

1.833.844.5350Customer Care and mail-order pharmacy contact number

Coverage Criteria

Prior Authorization

Covered when all of the following are met:

Prior authorization approval

The requested medication requires prior authorization; the prescriber submits the necessary clinical information; and the health plan approves coverage under criteria established by the Pharmacy & Therapeutics Committee.

Step Therapy

Step therapy is satisfied when either pathway applies:

Step therapy pathway

The member's prescription history confirms prior use of the required generic or first-line preferred medication.
If the preferred medication is not found in prescription history, the prescriber submits additional clinical information for health-plan review.

Non-formulary Coverage Exception

A non-formulary or non-covered medication may be considered when the formulary does not adequately meet the member's clinical needs and all of the following are met:

Medication coverage exception

The prescriber or authorized representative requests a medication coverage exception.
The request identifies the diagnosis and the requested drug, strength, and dosing schedule.
Supporting documentation demonstrates medical necessity, including formulary drugs previously tried and the reasons for treatment failure.

Opioid Management

Opioid-naive members may be subject to the following utilization-management requirements:

Opioid-naive opioid management

An immediate-release opioid formulation is used before progression to an extended-release formulation.
The first fill is limited to seven days.7 days
Opioid products, including combination products with acetaminophen, aspirin, or ibuprofen, are limited to up to 90 morphine milligram equivalents per day based on a 30-day supply.Up to 90 MME per day based on a 30-day supply

The outpatient formulary applies to prescription medications dispensed by participating pharmacies. It does not include inpatient medications or medications obtained from or administered by a physician.

Certain medication classes may be excluded under the applicable benefit plan, including supplements and weight-loss medications. Refer to the member’s benefit documents or contact Member Services to confirm whether a medication is excluded.

Specialty medications must be filled at a preferred specialty pharmacy. A specialty medication filled at an out-of-network specialty pharmacy will reject at the point of sale and will not be covered or reimbursed.

A non-formulary or non-covered medication may be considered when the formulary does not adequately meet the member’s clinical needs. The prescriber or authorized representative must request a coverage exception and provide documentation establishing medical necessity, including the diagnosis, requested drug, strength and dosing schedule, prior formulary drugs tried, and the reason for treatment failure. The request may be denied when medical necessity is not established or documentation does not show that a formulary option was tried and failed.

Quantity and Utilization Parameters

Opioid Daily Quantity

Daily limitUp to 90 morphine milligram equivalents (MME) per day

Supply basisBased on a 30-day supply

Above-limit reviewPrescriptions exceeding 90 MME daily are subject to utilization-management criteria, such as prior authorization

Opioid-Naive First Fill

Applies toMembers who are opioid-naive

Initial supplyThe first fill is limited to seven days

Related therapy sequenceImmediate-release opioid therapy is required before moving to an extended-release formulation

Provider Requirements and Denial Risks

Prior Authorization

Medication Prior Authorization Required

Certain medications require prior authorization before coverage. The prescriber must submit the necessary clinical information for health plan review and approval.

For medication request review assistance, call the Prior Authorization Hotline at 844.280.5833.

Prior Authorization

Age-Based Prior Approval

Certain drugs and products may require prior approval based on the member's age.

Call 844.280.5833 to obtain the drug- or product-specific age limits from a clinical reviewer.

Prior Authorization

High-Dose Opioid Authorization

Opioid prescriptions exceeding 90 morphine milligram equivalents (MME) per day on a 30-day supply are subject to utilization-management criteria, such as prior authorization.

Formulary Management Background

The formulary is maintained under the oversight of a Pharmacy & Therapeutics Committee composed of physicians and pharmacists. Formulary preferences and restrictions are maintained using clinical and operational considerations such as efficacy, safety, health outcomes, drug interactions, pharmacokinetics, contraindications, regulatory status, product labeling, peer-reviewed evidence, compendia, and evidence-based professional guidelines.

Key Definitions

Formulary

DefinitionA list of prescription drugs covered by a health plan

PurposePromotes use of cost-effective medications

Plan functionEstablishes the prescription drugs available for coverage under the health plan

Step Therapy

DefinitionA type of prior authorization

Review methodUses an electronic review of prescription history

Therapy reviewedConfirms that appropriate generic or first-line medications have already been tried

Opioid-Naive Initial Therapy

Opioid-naive Initial Therapy

For opioid-naive members, initial therapy is covered when all of the following are met:

Initial opioid therapy

An immediate-release opioid formulation is used before an extended-release formulation.
The first fill is limited to seven days.7-day first fill

Step Therapy Requirements

Step	Requirement
1	Try the required generic or first-line preferred medication before the requested therapy. If the preferred medication is not found in prescription history, the prescriber must submit additional clinical information for review.

Step	Requirement
1	For opioid-naive members, use an immediate-release opioid formulation before moving to an extended-release formulation.

Medication Quantity Limits

Opioid Quantity Limit

Covered productsOpioid products, including combination products with acetaminophen, aspirin, or ibuprofen

Maximum quantityUp to 90 morphine milligram equivalents per day

Supply basisBased on a 30-day supply

Opioid-Naive Initial Supply

Applies toOpioid products prescribed for opioid-naive members

Initial supply limitThe first fill is limited to seven days

Additional managementOpioid-naive members may be subject to additional step therapy requirements

Policy Summary

PayerCHRISTUS Health Plan Individual & Family Plan

PolicyPharmaceutical Management Procedures

Policy CodePolicy MC7746

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization before requesting coverage for medications designated as requiring prior approval.

SourceLink

On This Page

The limit applies to opioid products, including products combined with acetaminophen, aspirin, or ibuprofen.

Unsupported block type: prior_auth

Step Therapy

Generic or First-Line Therapy

Step therapy uses an electronic review of prescription history to confirm that the appropriate generic or first-line medication has been tried.

If the preferred drug history is found, the claim processes normally.
If the history is not found, submit additional clinical information for review through 844.280.5833.

Step Therapy

Immediate-Release Before Extended-Release Opioid

For opioid-naive members, an immediate-release opioid formulation may be required before progression to an extended-release formulation.

The first opioid fill may also be limited to seven days.

Documentation Required

Medical Necessity and Formulary Failure

Coverage requests must establish medical necessity and explain failure of formulary therapy. Documentation should identify the diagnosis, all formulary drugs tried, and the reason each failed or did not adequately address the member's needs.

Include supporting documentation such as progress notes, laboratory results, or published literature supporting safety and efficacy.
For non-covered drugs, document that the member has tried and failed a formulary option.

Documentation Required

Required Request Information

The prescriber or appointed representative must provide complete member, prescriber, medication, diagnosis, and supporting clinical information with each medication coverage request.

Patient name, date of birth, and member ID number.
Doctor's name and phone number.
Requested drug name, strength, and dosing schedule.
Diagnosis for which the drug is requested.
Necessary supporting documentation, such as progress notes, laboratory results, or published literature.
All drugs previously tried for the diagnosis and the reason for failure.

Denial Risk

Prior Authorization Not Approved

If a medication requires prior authorization, the claim will be denied at the pharmacy until the health plan reviews the clinical information and approves coverage.

Submit supporting clinical documentation showing that the member has tried and not responded to a formulary option.
For assistance, call 844.280.5833.

Denial Risk

Required Step Therapy Not Documented

When required preferred-therapy history is not documented, the pharmacy claim may be rejected and the prescriber must submit additional clinical information for health plan review.

Step therapy verifies prescription history for appropriate generic or first-line medications.
Contact 844.280.5833 for medication request review.

Denial Risk

Use a Preferred Specialty Pharmacy

All specialty medications must be filled at a preferred specialty pharmacy. Claims from an out-of-network specialty pharmacy reject at the point of sale and are not covered or reimbursed.

The rejection message may state “pharmacy not contracted.”

Denial Risk

Coverage Exception Not Supported

A coverage exception may be denied when the formulary adequately accommodates the member's clinical needs or when medical necessity and supporting documentation are not established.

Document that the member tried and failed a formulary option.
Provide the diagnosis, prior treatment history, failure rationale, and other requested clinical evidence.

Denial Risk

Opioid Dose Exceeds Limit

Opioid prescriptions exceeding the plan's 90 MME per day limit are subject to utilization-management review and may require prior authorization.

The threshold is based on a 30-day supply.
Additional step therapy and quantity limits may apply to opioid-naive members.

Specialty Medication

Cost and useTypically high-cost drugs used to treat or diagnose rare and complex diseases

MonitoringRequire close clinical monitoring and management

Handling and accessFrequently require special handling and may have limited access or distribution

Dispensing requirementMust be filled at a preferred specialty pharmacy

MME

Full termMorphine milligram equivalents per day

PurposeUsed to express the combined daily quantity of opioid products

Policy useUsed to limit the combined daily quantity of opioid products