MCO Pharmacy Formulary Review
Department of Social Services maintains formulary review procedures to help
ensure that each MCO’s formulary provides HUSKY members with adequate access
to drugs within each therapeutic drug classification. These procedures include the following:
Pharmacy Team initially reviews the formulary for each MCO to ensure that the
list adequately covers the pharmaceutical needs of HUSKY members.
The team provides comments and recommendations to DSS and is available to
advise DSS on formulary deletion requests.
review by DSS is required when an MCO adds a prescription drug to its formulary.
MCO is required to notify DSS when it proposes to delete a prescription drug
from its formulary. DSS requires 30
days notice before a deletion can be effected.
DSS reviews the change in its Managed Care and Pharmacy Units to make
sure that the change will continue to allow HUSKY members adequate access to
drugs in each therapeutic drug classification.
In the majority of cases, a drug is proposed for deletion because an
alternative or generic drug within that same classification has been added to
the formulary. In addition, DSS
provides for DCF review of all proposed deletions.
These reviews are typically conducted by Dr. Patricia Leebens.
regarding pharmacy denials: Except in cases of
cosmetic and non-covered prescription drugs (e.g. experimental), the reasons for
denial are usually due to there being an alternative drug that is on the MCO’s
formulary. Most denials for
non-formulary drugs (or for formulary drugs that require prior authorization)
are the result of the prescribing provider’s failure to give complete clinical
documentation to support the medical need for the non-formulary versus formulary
drug. An MCO will typically support
a non-formulary drug if complete clinical documentation is provided.