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    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsExecutive Office of Health and Human Services PDL …
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    CurrentExecutive Office of Health and Human ServicesPolicy N/A

    Pharmacy & Therapeutics Committee - PDL Formulary Recommendations (Coverage Criteria)

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    Summarizes P&T committee recommendations and formulary changes for multiple therapeutic drug classes that affect Medicaid pharmacy preferred status and utilization management; intended for pharmacy/program administrators and providers interacting with the Medicaid PDL.

    Policy Summary
    PayerExecutive Office of Health and Human Services
    PolicyPharmacy & Therapeutics Committee - PDL Formulary Recommendations (Coverage Criteria)
    Policy CodePolicy N/A
    Change TypeFormulary status updates (preferred / non-preferred movements)
    Effective DateOct 1, 2021
    Next Review DateDec 15, 2021
    Key ActionFail one preferred agent before accessing a non-preferred immunologic agent.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    unanimouscommittee votes on recommendations
    87%antibiotics, GI compliance
    24%influenza antivirals compliance

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    100%
    methotrexate agents compliance
    20%self-administered epinephrine compliance

    Formulary Recommendations & Coverage Decisions

    Formulary Recommendations

    Committee recommendations (covered when preferred status applies; some products were explicitly moved between preferred and non-preferred):

    Anti-infectives (selected changes): Continue current preferred agents with specified changes: make acyclovir suspension non-preferred (HSV); move Relenza to non-preferred (influenza); make Suprax chewable, capsules and suspension non-preferred (cephalosporins).

    Patients currently taking acyclovir suspension will be grandfathered into access.

    Antifungals, Oral: Continue current preferred agents and add clotrimazole as preferred.
    Hepatitis C Agents: Continue current preferred agents; noted updated indications for Sovaldi, Harvoni, and Mavyret and discontinuation of Ribasphere (generics still available). DUR to assess completion of therapy and reinfection rates.

    Ask DUR to look at completion of therapy per committee discussion.

    Dermatological Agents (selected changes): Continue current preferred agents with changes: move imiquimod to non-preferred; move alclometasone diproprionate (low group) ointment to non-preferred.

    There were no prescriptions during the quarter for imiquimod; one prescription for alclometasone (low group).

    Immunologics: Continue current preferred agents with change: move Enbrel vial to preferred. Committee noted that to access a non-preferred immunologic agent a patient needs to fail one agent.

    Failure of one preferred agent is expected before accessing non-preferred immunologic agents per committee discussion.

    Otics/Other changes: Continue current preferred agents with changes: move ciprofloxacin (otic) to non-preferred and move ofloxacin (otic) to preferred to reflect prescriptions dispensed in the quarter.
    Respiratory: Continue current preferred agents with change: add Advair Diskus to preferred; updated age indications for Dulera and Asmanex and a new digital inhaler noted.
    Urologics/GYN: Add Orlissa and Oriahnn as preferred agents on the PDL for the new uterine disorder treatments category (no utilization in the quarter).

    The committee designated several specific products as non-preferred on the PDL: imiquimod (immunomodulators, topical) and alclometasone dipropionate ointment (steroid, topical — low group) were moved to non-preferred status, and the minutes note these changes passed unanimously. Additionally, in anti-infectives the committee moved acyclovir suspension (HSV), Relenza (influenza), and Suprax formulations (chewable, capsules, suspension) to non-preferred. The document reports that patients currently taking some of these products (e.g., acyclovir suspension) will be grandfathered for continued access where applicable.

    Provider Impact & Prior Authorization Notes

    Prior Authorization

    PDL status changes may affect prior authorization

    Several products were moved to non-preferred status (for example: acyclovir suspension, Relenza, Suprax chewable/caps/suspension, imiquimod, alclometasone diproprionate ointment). These PDL changes may change prior authorization expectations for prescriptions of those agents; providers should anticipate that prescriptions for non-preferred products could require prior authorization or different PDL handling.

    • Acyclovir suspension — moved to non-preferred [[see citation]]
    • Relenza — moved to non-preferred
    • Suprax (chewable, caps, suspension) — moved to non-preferred
    • Imiquimod — moved to non-preferred
    • Alclometasone diproprionate (low group) ointment — moved to non-preferred
    Step Therapy

    Fail one preferred agent before non-preferred immunologic

    For non-preferred immunologic agents the committee confirmed that a patient must fail one agent before accessing a non-preferred product; providers should document an adequate trial and failure of a preferred agent when requesting access to a non-preferred immunologic.

    Step Therapy Requirements

    RequirementDetails
    Fail one preferred agentPatient must have failed one preferred immunologic agent prior to coverage of a non-preferred immunologic agent (committee discussion: 'to access a non-preferred agent does patient only need to fail one agent? Yes.')
    ApplicabilityApplies to non-preferred immunologic agents as noted in the P&T recommendations (e.g., agents moved to non-preferred status) — failure of one preferred agent is required before coverage consideration of a non-preferred immunologic agent.

    Policy Background & Committee Context

    These minutes summarize the Pharmacy & Therapeutics committee review across multiple therapeutic classes with category-specific utilization and compliance data and resulting formulary recommendations. Key utilization highlights include 87% compliance for antibiotics (GI) and 24% compliance for influenza antivirals; topical immunomodulators showed ~80% compliance and methotrexate agents 100%. The committee voted unanimously to continue existing preferred agents in most categories while making targeted adjustments — for example, moving certain products to non-preferred status (see criteria) and moving Enbrel vial to preferred among immunologics. The committee also discussed operational implications of non-preferred designations (potential impacts on prior authorization) and confirmed that access to non-preferred immunologic agents generally requires failure of one preferred agent, with additional DUR follow-up recommended for hepatitis C treatment completion and reinfection monitoring.

    Definitions & Key Terms

    Completion of therapy
    DefinitionCompletion of therapy: whether patients complete the prescribed antiviral regimen for hepatitis C (treatment course completion).
    Concern RaisedCommittee questioned rates of completion of therapy and noted re-infection occurs in other states; requested DUR to examine completion of therapy for hepatitis C.
    ImplicationCompletion rates and re-infection data may inform utilization review and ongoing coverage of preferred hepatitis C agents.
    Related actionsRecommendation made to continue current preferred hepatitis C agents while asking DUR to assess therapy completion and re-infection rates.
    Examples referencedUpdated indications noted for Sovaldi, Harvoni, and Mavyret; Ribasphere discontinued (generics available).
    Policy Summary
    PayerExecutive Office of Health and Human Services
    PolicyPharmacy & Therapeutics Committee - PDL Formulary Recommendations (Coverage Criteria)
    Policy CodePolicy N/A
    Change TypeFormulary status updates (preferred / non-preferred movements)
    Effective DateOct 1, 2021
    Next Review DateDec 15, 2021
    Key ActionFail one preferred agent before accessing a non-preferred immunologic agent.
    SourceLink
    On This Page
    Formulary Recommendations & Coverage DecisionsProvider Impact & Prior Authorization NotesStep Therapy RequirementsPolicy Background & Committee ContextDefinitions & Key Terms
    • Requirement per committee discussion: failure of one preferred agent is expected before non-preferred immunologic access.
    • Document clinical rationale and prior therapy when submitting authorization requests.
    Documentation Required

    DUR review required for hepatitis C treatment completion

    The committee asked DUR to review completion of hepatitis C therapy and reinfection rates; utilization review follow-up may be initiated to assess treatment completion and re‑infection.

    • DUR review requested to examine completion of therapy and reinfection.
    • Providers should expect possible DUR-driven utilization review related to hepatitis C treatment management.
    Denial Risk

    Non-preferred changes can trigger denials or step edits

    Because several products were designated non-preferred, prescriptions for those agents may be subject to prior authorization, step edits, or denial if coverage criteria are not met; providers should verify PDL status and follow applicable authorization or step therapy requirements.

    • Non-preferred agents listed in the minutes may require PA or will be subject to PDL restrictions.
    • Check PDL and submit required documentation or evidence of failed preferred therapy to avoid claim denials.