Pharmacy & Therapeutics Committee - Formulary and Prior Authorization Decisions (April 5, 2011)
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Summarizes Pharmacy & Therapeutics Committee decisions about preferred/non-preferred status, formulary changes, and prior authorization considerations that affect Rhode Island Medicaid drug coverage and pharmacy administration.
Pantoprazole (new generic proton pump inhibitor) was added as preferred.
Nutropin AQ and Norditropin were added as preferred growth hormone products.
Gilenya (fingolimod) was added to the multiple sclerosis class as non-preferred.
Ampyra was removed from the Multiple Sclerosis class for separate review and potential clinical edit as an add-on therapy.
Atelvia and Prolia (bone resorption agents) were new entities but not added as preferred.
Kombligyze XR (incretin mimetic/enhancer) and Bromday (ophthalmic) were new entities but not added as preferred.
Veltin (topical acne agent) was added as non-preferred.
ActosPlusMet XR (TZD combination oral hypoglycemic) was added as non-preferred.
Avandia (rosiglitazone) was placed as non-preferred with use limited based on detailed prescriber documentation; existing clients grandfathered.
Formulary and Coverage Determinations
Formulary determinations
Covered status determined per drug/class as follows:
DUR Board to consider a clinical edit for Ampyra
No changes were made for the classes Injectable Hypoglycemics and Topical Psoriasis Agents at this P&T meeting; no new agents were added and no status changes occurred for these classes.
The minutes do not designate any product as not medically necessary. Coverage status changes and new-entity placements described in the report reflect preferred/non-preferred decisions but do not include any explicit not-medically-necessary determinations.
Prescriber and Pharmacy Actions / Prior Authorization
Prior authorization likely for non-preferred agents
The committee placed certain non-preferred agents (for example, Avandia/rosiglitazone) with limits on use; prescribers should expect prior authorization or similar justification requirements when requesting these non-preferred agents.
Possible step/add-on therapy edit for Ampyra
Ampyra (dalfampridine) was determined to be an add-on to existing multiple sclerosis therapy rather than a substitute; the DUR Board will consider a clinical edit treating Ampyra as add-on therapy rather than allowing substitution.
Avandia prescriber documentation required
Detailed prescriber documentation is required to justify use of Avandia (rosiglitazone) after the committee placed it as non-preferred; existing clients will be grandfathered.
- Be prepared to supply detailed clinical justification from the prescriber when requesting Avandia for a member.
- Existing clients on Avandia at the time of this decision are grandfathered and not subject to new limits.
Documentation risk for Avandia requests
Use of Avandia may be limited and lack of adequate prescriber documentation could result in denial of coverage for the request.
- Requests without the required detailed prescriber documentation are at risk for denial.
Meeting Summary and Rationale
The Pharmacy & Therapeutics committee minutes summarize reevaluation of multiple drug classes and specific product decisions. The report notes additions of certain preferred products (for example, Pantoprazole as a newly available generic added as preferred, and Nutropin AQ and Norditropin added as preferred growth hormones), placement of new entities as non-preferred (for example, Veltin in topical acne agents), and several new entities that were not added as preferred (for example, Atelvia, Prolia, Kombligyze XR, and Bromday). The minutes also state there were no new drug classes reviewed at this meeting and identify program-level implications such as formulary shifts and the impacts of timing on claims review (for example, incomplete claims data following a flood that affected switching analysis in the topical acne class).
Terminology and Therapy Type Definitions
Step Therapy / Clinical Edit Plans
| Drug / Edit | Planned step therapy action |
|---|---|
| Ampyra | May be managed via a clinical edit as an add-on therapy (not a substitute). The drug was removed from the Multiple Sclerosis class for separate review; the DUR Board will develop the specific step/add-on therapy edit. |
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