Fee for Service: Pharmacy & Therapeutics Committee Meeting Minutes — Coverage Criteria
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Summarizes the September 10, 2024 Fee-for-Service Pharmacy & Therapeutics Committee meeting including attendance, therapeutic class reviews, motions, and public testimony; intended for internal stakeholders and providers affected by formulary or prior authorization changes discussed.
No material clinical or coverage changes in this revision.
Coverage Criteria Summary
No explicit exclusions or not-covered conditions were documented in the meeting minutes for the September 10, 2024 Pharmacy & Therapeutics Committee meeting. The minutes summarize therapeutic class reviews and motions but do not list any specific services, diagnoses, or drugs that the committee designated as excluded from coverage.
The minutes contain no explicit determinations that any drug or service is not medically necessary. Discussions focused on therapeutic class reviews, formulary status recommendations (e.g., preferred/non-preferred designations), and category compliance metrics rather than formal NMN rulings.
Provider Actions and Formulary Impacts
Formulary status changes for select anti‑migraine agents
Meeting minutes record a recommendation to move Qulipta (spelled as “Quilipta” in the minutes) and Ubrelvy to preferred status, and to designate Nurtec ODT as non-preferred; these formulary status changes may prompt future formulary or prior authorization updates. Note the drug name discrepancy: Qulipta is listed as “Quilipta” in the minutes — providers should be aware of both spellings when reviewing communications or PA lists.
- Qulipta appears in the minutes as “Quilipta”; recommended to move to preferred.
- Ubrelvy recommended to move to preferred.
- Nurtec ODT recommended to be non-preferred.
No step therapy requirements documented
The committee minutes do not record any explicit step therapy requirements or specific step-edit sequences for anti-migraine agents or other categories; no step edits were specified during the documented discussion.
- Minutes state: “No explicit step therapy steps were documented; committee recommended preferred/non-preferred changes which could affect step edits but none were specified.”
Send public testimony follow‑up to committee contact
Public testimony follow-up should be sent to karen.mariano@gainwelltechnologies.com for distribution to the committee.
- Follow-up contact for public testimony: karen.mariano@gainwelltechnologies.com
No explicit denial triggers recorded
The minutes contain no explicit denial triggers or operational denial criteria; however, the discussed formulary status changes (preferred/non‑preferred designations) could indirectly affect future coverage decisions or denials if implemented.
- Minutes state there were formulary status recommendations (preferred/non-preferred) but no recorded denial triggers or PA denial criteria.
Step Therapy Considerations
| Step | Requirement / Notes | Potential impact on step edits |
|---|---|---|
| No explicit steps documented | Meeting minutes state that no explicit step therapy requirements were recorded; committee discussion focused on formulary status changes (recommended Quilipta and Ubrelvy to preferred, Nurtec ODT to non-preferred) rather than defining step sequence or failure criteria. | Formulary status changes could prompt future step edits (e.g., preferencing Quilipta/Ubrelvy or deprioritizing Nurtec ODT) but no operational step edits or implementation details were specified in the minutes. |
Therapeutic Category Compliance Metrics
Background and Meeting Context
The meeting minutes summarize therapeutic class reviews presented by Magellan Medicaid Administration and include public testimony from manufacturers and representatives. Reviews covered multiple classes — including Analgesic Agents, Anti-migraine Agents (Triptans and others), Long-Acting and Short-Acting Narcotic Analgesics, and NSAIDs — and reported category compliance rates (examples: 94.0% for Analgesic Agents; 16.7% for Triptans; 51.2% for Long-Acting Narcotics; 100.0% for Short-Acting Narcotics and NSAIDs). The minutes record commentary and committee motions, including recommendations to change formulary status for specific anti-migraine agents (for example, moving Quilipta and Ubrelvy to preferred status and designating Nurtec ODT as non-preferred), notes on FDA labeling updates for long-acting narcotics, and a request for DUR review related to opioid use in chronic and long-term care settings.
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