CurrentCHRISTUS Health Plan of Texas and LouisianaPolicy H1189_MC7745_C

Pharmaceutical Management Procedures

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This policy governs formulary management, specialty pharmacy requirements, prior authorization, step therapy, quantity and age limits, generic and preferred-brand substitution, opioid limits, and medication coverage exceptions for CHRISTUS Health Plan Medicare Advantage pharmacy benefits. It applies to providers requesting outpatient prescription drug coverage for members.

Policy Summary

PayerCHRISTUS Health Plan of Texas and Louisiana

PolicyPharmaceutical Management Procedures

Policy CodePolicy H1189_MC7745_C

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required clinical information and supporting documentation when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 MME/dayOpioid quantity threshold based on a 30-day supply

7 daysInitial opioid-naive first-fill limit

3Medication request submission channels or contact routes

Preferred specialty pharmacy

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CurrentCHRISTUS Health Plan of Texas and LouisianaPolicy H1189_MC7745_C

Pharmaceutical Management Procedures

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Get alerted when Policy H1189_MC7745_C changes without checking for updates manually.

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Policy Summary

PayerCHRISTUS Health Plan of Texas and Louisiana

PolicyPharmaceutical Management Procedures

Policy CodePolicy H1189_MC7745_C

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required clinical information and supporting documentation when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 MME/dayOpioid quantity threshold based on a 30-day supply

7 daysInitial opioid-naive first-fill limit

3Medication request submission channels or contact routes

Preferred specialty pharmacy

Specialty medication dispensing requirement

8Required information elements for coverage exception requests

Pharmacy Coverage Criteria

Prior Authorization

Coverage requires health plan review and approval before the medication will be covered.

ALL of the following

The medication is subject to CHRISTUS Health Plan prior authorization requirements.
The prescribing doctor submits the necessary clinical information for review.
The request meets the coverage criteria established by the Pharmacy & Therapeutics Committee.
Supporting clinical documentation demonstrates that the member has tried and not responded to a formulary option, when applicable.
A medication requiring prior authorization will be denied at the pharmacy until the health plan reviews the clinical information and approves coverage.

Step Therapy

Step therapy coverage requires confirmation that appropriate preferred therapy has been tried.

ALL of the following

The prescription is subject to step-therapy requirements.
The member's prescription history confirms prior use of the appropriate generic or first-line preferred drug(s).
When preferred-drug use is found, the claim processes normally and the applicable pharmacy copayment applies.
If the preferred drug(s) are not found in the prescription history, the prescribing doctor submits additional clinical information for health plan review.
The claim will be rejected at the pharmacy until the additional review is completed.

Medication Coverage Exception

A medication coverage exception may be requested when the formulary does not adequately accommodate the member's clinical needs.

ALL of the following

The requested drug or product is non-covered or does not adequately meet the member's clinical needs under the formulary.
The prescribing doctor or appointed representative submits a medication coverage exception request.
The request includes supporting clinical documentation demonstrating medical necessity, including that the member has tried and failed a formulary option.
The request is submitted for clinical review by calling the Prior Authorization Hotline at 855.344.0930 or faxing a letter of medical necessity or applicable prior authorization request form to 1.855.633.7673.
The health plan approves the exception after review of the clinical information.

Opioid Management

Opioid coverage is subject to daily morphine milligram equivalent, prior authorization, step-therapy, and quantity-limit controls.

ALL of the following

The total quantity of opioid products prescribed, including products combined with acetaminophen, aspirin, or ibuprofen, is within 90 morphine milligram equivalents (MME) per day based on a 30-day supply.<= 90 MME/day
ONE of the following applies
- The prescription does not exceed the 90 MME daily limit.
- If the prescription exceeds 90 MME per day, it meets applicable utilization-management criteria, such as prior authorization.
For opioid-naïve members, ALL applicable requirements apply

All specialty medications must be filled at a preferred specialty pharmacy. Specialty medications filled at an out-of-network specialty pharmacy will reject at the point of sale as “pharmacy not contracted” and will not be covered or reimbursed.

The formulary applies only to outpatient prescription medications dispensed by participating pharmacies. It does not include inpatient medications or medications obtained from and/or administered by a doctor. The formulary, including its restrictions and preferences, is available through an online search and as a printable document. Certain medication classes, including supplements or weight-loss medications, may not be covered; members should consult their benefit documents or contact Member Services to determine exclusions under their benefit plan.

Medication coverage exception requests must include the patient's name, date of birth, member ID number, doctor's name and phone number, requested drug name, strength, and dosing schedule, and the diagnosis for which the drug is requested. Include necessary supporting documentation, such as progress notes, laboratory results, or published literature supporting safety and efficacy, as well as all drugs previously tried for the diagnosis and the reason each failed. Requests may be initiated by the doctor or appointed representative by calling 855.344.0930; the Prior Authorization Team fax number is 1.855.633.7673. For assistance with a medication request review, call 844.280.5833.

Utilization and Quantity Parameters

Opioid daily dose

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

Supply basisBased on a 30-day supply

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

Opioid-naïve first fill

Applicable membersMembers who are opioid-naïve

First-fill limitLimited to seven days

Additional managementOpioid-naïve members may also be subject to step therapy and quantity limit restrictions

Submission, Authorization, and Denial Rules

Prior Authorization

Prior Authorization Required

Certain medications require prior authorization before coverage. These drugs are identified by the Pharmacy & Therapeutics Committee and may be subject to authorization because they are high-cost, limited to specific diagnoses, or not recommended as first-line therapy. If required authorization is missing, the pharmacy claim will be denied until clinical information is reviewed and coverage is approved.

Submit clinical information demonstrating medical necessity and that formulary alternatives were tried and did not work.
For medication request review assistance, call 844.280.5833.

Prior Authorization

Age-Based Prior Approval

CHRISTUS Health Plan may require prior approval for certain drugs or products based on the member's age. A clinical reviewer will provide the drug- or product-specific age limits when requested during the call.

Request the applicable age limit from a clinical reviewer when submitting or discussing the medication request.

Formulary Management Context

The formulary is developed and continuously updated by a Pharmacy & Therapeutics Committee composed of physicians and pharmacists. Coverage preferences consider efficacy, safety, health outcomes, drug interactions, pharmacokinetics, contraindications, regulatory status, clinical literature, evidence-based guidelines, and cost efficiency. The formulary and its restrictions and preferences apply to outpatient prescription medications dispensed by participating pharmacies; specialty medications generally treat rare or complex conditions and may require close monitoring, special handling, or limited distribution.

Key Pharmacy Terms

Formulary

DefinitionA list of prescription drugs covered by a health plan

PurposeDesigned to promote the use of the most cost-effective medications

AdministrationDeveloped and continuously updated by a committee of physicians and pharmacists

Specialty medication

CostTypically high-cost drugs

RoutesMay be oral, topical, inhaled, inserted, implanted, or injected

Uses and characteristicsUsed to treat or diagnose rare and complex diseases; often requires close clinical monitoring, special handling, or limited access or distribution

Opioid Initial Therapy

Opioid-Naive Initial Therapy

Covered when the following initial therapy requirement is met:

Initial opioid therapy: For an opioid-naive member, use an immediate-release opioid formulation before moving to an extended-release formulation.

The first fill may be limited to seven days.

Required Treatment Sequence

Step	Try first	Then consider
1	Appropriate generic or first-line preferred medication	Requested medication

Step	Try first	Then consider
1	Immediate-release (IR) opioid formulation	Extended-release (ER) opioid formulation

Medication Quantity Parameters

Opioid quantity limit

Products includedOpioid products, including combinations with acetaminophen, aspirin, or ibuprofen

Maximum doseUp to 90 morphine milligram equivalents (MME) per day

Supply basisBased on a 30-day supply

Opioid-naïve quantity limit

Applicable membersMembers who are opioid-naïve

First-fill limitSeven days

Related requirementAn immediate-release formulation is required before moving to an extended-release formulation

Specialty Pharmacy Dispensing

Billing Rule

Fill specialty medications at the preferred pharmacy

All specialty medications must be filled at a preferred specialty pharmacy. Out-of-network specialty pharmacy fills reject at the point of sale as “pharmacy not contracted” and are not covered or reimbursed.

Policy Summary

PayerCHRISTUS Health Plan of Texas and Louisiana

PolicyPharmaceutical Management Procedures

Policy CodePolicy H1189_MC7745_C

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required clinical information and supporting documentation when requesting prior authorization.

SourceLink

On This Page

An immediate-release (IR) opioid formulation is used before an extended-release (ER) formulation.

The first fill is limited to seven days.<= 7 days

Prior Authorization

Opioid Doses Above 90 MME

Opioid prescriptions exceeding the plan's daily threshold are subject to utilization-management criteria, which may include prior authorization.

The limit is up to 90 morphine milligram equivalents (MME) per day based on a 30-day supply.
The limit applies to opioid products, including combinations with acetaminophen, aspirin, or ibuprofen.
Opioid-naive members may also be subject to a seven-day first-fill quantity limit.

Prior Authorization

Submit a Coverage Exception

A doctor or the doctor's appointed representative may request a medication coverage exception when the formulary does not adequately accommodate the member's clinical needs. Non-covered drug requests may be reviewed by calling 844.280.5833.

Call the Prior Authorization Hotline at 855.344.0930; the Call Center will ask clinical questions and may approve coverage or request additional information for clinical review.
Alternatively, fax a letter of medical necessity or the applicable prior authorization request form to the Prior Authorization Team at 1.855.633.7673.

Step Therapy

Preferred Therapy Trial Required

Step therapy requires documentation that the appropriate generic, preferred, or first-line medication has already been tried. When the preferred drug is found in the prescription history, the claim processes normally; otherwise, the pharmacy claim is rejected and additional clinical information is required.

Document an adequate trial of the appropriate generic or preferred medication before requesting coverage of the non-preferred drug.
For medication request review, call 844.280.5833.

Step Therapy

Immediate-Release Opioid Step

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

Use and document the required immediate-release (IR) formulation before moving to an extended-release (ER) formulation.
Additional quantity-limit restrictions may apply, including a first fill limited to seven days.

Unsupported block type: documentation;

Documentation Required

Document Formulary Failure

Coverage exceptions and prior authorization requests must show that formulary alternatives were tried and failed when the formulary does not adequately meet the member's clinical needs.

Identify every drug previously tried for the treated diagnosis.
Describe the reason for failure or lack of response for each formulary alternative.
Include the supporting clinical documentation with the request.

Documentation Required

Clinical Support Required

Support the medical-necessity request with clinical records sufficient for the plan to evaluate safety, efficacy, and the member's response to prior therapy.

Provide progress notes and relevant laboratory results.
Include published literature supporting the requested drug's safety and efficacy when applicable.

Denial Risk

Use a Preferred Specialty Pharmacy

All specialty medications must be filled through 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.

Use a preferred specialty pharmacy for specialty medications.
The point-of-sale rejection message is “pharmacy not contracted.”

Denial Risk

Missing Prior Authorization

When a medication requires prior authorization, the pharmacy claim will be denied until the health plan reviews the required clinical information submitted by the doctor and approves coverage.

Submit the required clinical information before dispensing the medication.
Be prepared to show that the member tried and did not respond to a formulary option.
For assistance with medication request review, call 844.280.5833.

Step Therapy

Step Therapy Not Satisfied

If the preferred drug is not found in the member's prescription history, the pharmacy claim will be rejected and the provider must submit additional clinical information for health plan review.

Confirm that the appropriate generic or first-line therapy was tried before prescribing the requested medication.
If the trial is not reflected in the prescription history, submit documentation of the trial and outcome.
For medication request review, call 844.280.5833.

Denial Risk

Opioid Threshold Exceeded

Opioid prescriptions above 90 MME per day are subject to utilization-management criteria, such as prior authorization, and may not process without approval.

Calculate total opioid exposure across products, including combination products, using a 30-day supply.
Prescriptions above 90 MME daily require clinical review under applicable utilization-management criteria.
For opioid-naive members, verify the IR-before-ER step and applicable first-fill quantity limit.

Prior authorization

DefinitionApproval required before certain medications are covered

When requiredTypically when a medication is not recommended as a first-line treatment, is limited to specific diagnoses, or is high-cost

PurposeEnsures medications are prescribed in a safe, appropriate, and cost-effective way

Step therapy

DefinitionA type of prior authorization that electronically reviews prescription history

Required historyConfirms that appropriate generic or first-line medications have already been tried

If history is absentThe claim is rejected at the pharmacy and the doctor must submit additional clinical information for review

Generic substitution

DefinitionUse of a generic drug when the U.S. Food and Drug Administration has determined it is equivalent to the brand-name drug

AvailabilityApplies subject to availability of the generic

State-law considerationSubject to state regulations regarding drug product selection

Formulary quantity limits

Applicable productsCertain medications or products covered under the pharmacy benefit

Limit typeDrug-specific quantity limits

Where listedThe limits are listed in the downloadable formulary on the CHRISTUS Health Plan website