Preferred Drug List (PDL) Governance and Pharmacy Management
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Defines the Centene Preferred Drug List (PDL) governance, pharmacy management controls (e.g., prior authorization, quantity limits, step therapy), and processes for maintaining and updating the PDL for Peach State Health Plan (Medicaid). Affects plan pharmacy departments, Centene P&T, CPAC, SDC, providers, and members.
No material clinical or coverage changes in this revision.
Preferred Drug List (PDL) Coverage Criteria
PDL construction and pharmaceutical management criteria
Criteria used when adopting pharmaceutical management procedures and constructing the PDL include:
From PROCEDURE item 1 and subitems
Negative PDL changes (that is, changes that result in restrictions or replacements) will be communicated only to the affected members and their prescribing practitioners. Communications for PDL updates occur annually via member and provider newsletters or other materials, but significant changes trigger targeted provider outreach (email blast, fax blast and/or newsletter) and member notification via newsletter or mail as described in the PDL update process.
Provider Responsibilities and Operational Controls
Prior authorization determination by Corporate P&T (with CPAC input)
The Centene Corporate Pharmacy & Therapeutics (P&T) Committee is responsible for approving all changes to the Centene PDL and determines which PDL drugs require pharmaceutical management edits, including prior authorization; the Clinical Pharmacy Advisory Committee (CPAC) provides the CPAC rationale for prior authorization along with a draft of the prior authorization criteria when there is significant potential for inappropriate use.
- Centene Corporate P&T approves all PDL changes and determines which drugs require prior authorization.
- CPAC provides rationale and a draft of PA criteria when significant potential for inappropriate use is identified.
Notification for significant PDL changes
If significant changes to the PDL are made, the Health Plan will notify providers via Eblast, Faxblast and/or newsletter and will notify affected members via newsletter or mail; the most current PDL is also maintained on the plan website on an annual basis.
- Provider communication methods: Eblast, Faxblast, and/or newsletter.
- Member notification: newsletter or mail.
- PDL availability: maintained annually on the website.
Step-therapy protocols included on the PDL
Step-therapy protocols are included as a pharmacy management method on the PDL and may be applied to specific drugs or therapeutic classes as determined by P&T; step-therapy considerations are part of the criteria used when constructing the PDL.
- Step therapy may be enforced per drug or class as determined by P&T.
- Step-therapy is one of the management methods considered when adopting PDL controls.
Health Plan variance requests to Corporate P&T
The Health Plan may request variances from Corporate P&T Committee recommendations for additions, deletions or limitations of PDL coverage, but such requests must be submitted with required supporting materials and require Health Plan P&T Committee agreement by a quorum vote before forwarding.
- Variance requests must include clinical rationale, pharmacoeconomic comparisons, or State-mandated coverage/exclusion language.
- Requests must include Health Plan P&T Committee agreement by a quorum approval vote prior to submission.
Submit PDL change requests in writing to health plan pharmacist
Providers must submit requests for changes to the PDL in writing to the health plan pharmacist and substantiate the request with appropriate clinical rationale for consideration.
- Submit change requests in writing to the health plan pharmacist.
- Include appropriate clinical rationale to support the request.
Required clinical rationale and supporting materials for variance requests
Health Plan requests for PDL variances must include clinical rationale such as peer‑reviewed articles, published studies, or guidelines supported by professional medical organizations, or pharmacoeconomic drug comparison studies, or State-mandated coverage/exclusion language.
- Acceptable supporting materials: peer‑reviewed articles, published studies, or professional guidelines.
- Also acceptable: pharmacoeconomic drug comparison studies or State-required mandates for coverage/exclusion.
Pharmaceutical management edits may trigger denial if requirements unmet
Drugs on the PDL may be subject to pharmaceutical management edits—prior authorization, quantity limits, age/gender edits, and step therapy—and lack of required PA or other edits may result in claim denial.
- Pharmaceutical management edits that may trigger denial include prior authorization, quantity limits, and age/gender edits.
- Ensure required edits are met before dispensing to avoid denial.
Forward reconsideration requests to Corporate Pharmacy P&T
Requests for reconsideration of Corporate P&T recommendations should be forwarded to the Corporate Pharmacy team for presentation and review by the Corporate Pharmacy P&T Committee; final disposition will be decided by the Corporate P&T Committee.
- Forward reconsideration requests to the Corporate Pharmacy team for presentation.
- Final decisions are made by the Corporate P&T Committee after review.
Step-Therapy Protocols
| Policy statement | Notes / application |
|---|---|
| Step-therapy protocols are part of the Preferred Drug List (PDL) | Step-therapy may be applied to individual drugs or entire pharmaceutical classes as determined by the Centene P&T Committee and implemented in the PDL; step therapy is listed as one of the pharmacy management procedures the PDL describes. |
Terminology
Background and Scope
This document is administrative and governance-focused and defines processes for maintaining the Preferred Drug List (PDL), including review, acceptance, coding, and publication of formulary changes. Health plan pharmacy leads review recommendation packets and communicate acceptance or rejection; accepted changes are submitted for coding and web synchronization. The policy establishes an annual cadence for communicating the availability of the current PDL to members and providers, with additional targeted notifications when significant changes occur.
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