R414-60B. Preferred Drug List, R414. Health, Health Care Financing, Coverage and Reimbursement Policy, Utah Administrative Code

Utah Administrative Code (Current through November 1, 2019)

R414. Health, Health Care Financing, Coverage and Reimbursement Policy

R414-60B-1. Introduction and Authority

Latest version.

(1) The Division of Medicaid and Health Financing (DMHF) has established a Preferred Drug List (PDL) to operate within the pharmacy program and at the Division's discretion.

(2) The Preferred Drug List is authorized under Section 26-18-2.4.

R414-60B-2. Client Eligibility Requirements

Latest version.

A PDL is available to categorically and medically needy individuals.

R414-60B-3. Program Access Requirements

Latest version.

A PDL is established for certain therapeutic classes of drugs and is available through the point of sale system of any Medicaid provider. At its discretion, DMHF establishes and implements the scope and therapeutic classes of drugs.

R414-60B-4. Service Coverage

Latest version.

(1) Upon the recommendation of the Pharmacy and Therapeutics (P&T) Committee, DMHF pharmacy staff select the therapeutic classes and select the most clinically effective and cost effective drug or drugs within each class.

(2) The prescriber must obtain prior authorization from the Department to dispense drugs designated as "non-preferred" in each class, through the Department's current prior authorization system. Criteria for a Non-preferred Prior Authorization (NPA) is established by the Department in consultation with the P&T Committee.

(3) A prior authorization is not placed on any preferred drugs under Section R414-60B-4. Nevertheless, a prior authorization may apply if set by the Drug Utilization Review Board (DURB).

(4) For NPA requests submitted during normal business hours, Monday through Friday, 8 a.m. to 5 p.m., the prior authorization system shall provide either telephone or fax approval or denial within 24 hours of the receipt of the request.

(5) In an emergency situation for a prior authorization needed outside of normal business hours, a 72-hour supply of a non-preferred drug may be dispensed and the Department shall issue an NPA for the 72-hour supply on the next business day. Further quantity requests shall be subject to all NPA requirements.

R414-60B-5. P&T Committee Composition and Membership Requirements

Latest version.

(1) There is created a P&T Committee within DMHF. The DMHF Director shall appoint the members of the P&T Committee for a two-year term. DMHF has the option of making the appointments renewable.

(2) DMHF staff request nominations for appointees from professional organizations within the state. These nominations are then given to the Director for selection and appointment.

(a) If there are no recommendations within 30 days of a request, DMHF may submit a list of potential candidates to professional organizations for consideration.

(b) If there are no willing nominees for appointment from professional organizations, the Director may seek recommendations from DMHF staff.

(3) The P&T Committee consists of one physician from each of the following specialty areas:

(a) Internal Medicine;

(b) Family Practice Medicine;

(d) Pediatrics.

(4) The P&T Committee consists of one pharmacist from each of the following areas:

(a) Pharmacist in Academia;

(b) Independent Pharmacy;

(d) Hospital Pharmacy.

(5) DMHF shall appoint one voting committee manager.

(6) Up to two non-voting ad hoc specialists participate on the committee at the committee's invitation.

(7) An individual considered for nomination must demonstrate no direct connection to and must be independent of the pharmaceutical manufacturing industry.

(8) The P&T Committee shall elect a chairperson to a one-year term from among its members. The chairperson may serve consecutive terms if reelected by the committee.

(9) When a vacancy occurs on the committee, the Director shall appoint a replacement for the unexpired term of the vacating member.

(10) P&T Committee members serve at the discretion of the DMHF Director.

R414-60B-6. P&T Committee Responsibilities and Functions

Latest version.

(1) The P&T Committee functions as a professional and technical advisory board to DMHF in the formulation of a PDL.

(2) P&T Committee recommendations must:

(a) represent the majority vote at meetings in which a majority of voting members are present; and

(b) include votes by at least one committee member from the group identified in Subsection R414-60B-5(3) and one member from the group identified in Subsection R414-60B-5(4)

(3) The P&T Committee manager shall schedule meetings, set agendas, provide meeting materials, keep minutes, record committee business, notify the Director when vacancies occur, provide meeting notices, and coordinate functions between the committee and DMHF.

(4) Notice for a P&T Committee meeting shall be given in accordance with applicable law.

(5) The P&T Committee chairperson shall conduct all meetings. The P&T Committee manager shall conduct meetings if the chairperson is not present.

(6) P&T Committee meetings shall occur at least quarterly.

(7) P&T Committee meetings shall be open to the public except when meeting in executive session.

(8) The committee shall:

(a) review drug classes and make recommendations to DMHF for PDL implementation;

(b) review new drugs, new drug classes or both, to make recommendations to DMHF for PDL implementation;

(d) review drugs within a therapeutic class and make a recommendation to DMHF for the preferred drug or drugs within the therapeutic class; and

(e) review evidence based criteria and drug information.

R414-60B-7. Clinical and Cost-Related Factors

Latest version.

The P&T Committee shall base its determinations on the following factors as established by the DURB:

(1) If clinical and therapeutic considerations are substantially equal, then the P&T Committee shall recommend to DMHF that it consider only cost.

(2) In making its recommendations to DMHF, the P&T Committee may also consider whether the clinical, therapeutic effects, and medical necessity requirements justify the cost differential between drugs within a therapeutic class.