Who Decides What's Covered?
|
|
|
|
How does HealthPartners decide which medications to put on the preferred drug list*? Who makes the decisions—and on what basis? We're glad you asked!
Thousands of drugs are on the market, and new ones are being introduced all the time. To make sure our members get quality, safe and cost-effective medications, we continually review and evaluate new and existing drugs.
Read on to learn exactly how our process workswhat's in, what's out and why.
Our Guiding Principles
Here, in order of importance, are the nine guiding principles used to develop and maintain the preferred drug list.
1. Look for proven effectiveness, documented in medical literature.
First and foremost, medical literature has to document that the drug works well. To determine this, we look at randomized controlled clinical trials published in peer-reviewed medical journals. We also consider observational studies and medical opinion.
2. Strive to maximize safety and minimize the potential for errors.
We compare the risks and benefits of a given drug with other treatments. This includes looking at its potential for causing serious adverse reactions, as well as such things as possible name confusion.
3. Improve the overall value.
When evaluating a new drug or therapy, we compare its value relative to existing treatments in both medical outcomes and medication costs.
4. Emphasize products essential to health.
Cosmetic and lifestyle medications, such as Propecia® for hair loss, are generally excluded from the preferred drug list.
5. Eliminate unnecessary duplication.
We favor unique medications that have advantages in effectiveness, safety or value over other drugs currently available.
6. Strive to improve patient compliance and satisfaction.
We favor products that are significantly more convenient for patients and that help increase patient satisfaction while maintaining overall value.
7. Support protocols developed by the Institute for Clinical Systems Improvement and consider other locally adopted treatment procedures.
The Institute is a collaborative organization of medical groups, including HealthPartners Medical Group, committed to improving healthcare quality. The Institute features a physician-led, physician-governed process to review the best available research and to create "best-practice" protocols. These protocols represent the current thinking on the best way to handle specific medical issues.
8. Provide long-term stability of the preferred drug list.
Because it is important for members to have continuity in their care, we try to keep the preferred drug list as stable as possible while still being responsive to a changing marketplace.
9. Serve all members.
While the preferred drug list serves the majority of our members well, we also have processes in place for obtaining medications that are not on the preferred drug list. Providers may request either a prior approval for using certain drugs or request that a drug not found on the preferred drug list be covered.
How Drugs are Chosen
The HealthPartners Pharmacy and Therapeutics (P&T) Committee is responsible for maintaining our outpatient preferred drug list. The committee includes practicing physicians and pharmacists from throughout HealthPartners.
These experts review the scientific data on new and existing drugs, select the ones that are both safe and effective, and regularly update our preferred drug list. The committee also relies on clinical pharmacists and work groups made up of practicing experts in various areas to review drug information and make recommendations.
The P&T Committee meets at least quarterly to review drug information and work-group recommendations, analyze data and present concerns. Categories of similar medications, such as heart medication or diabetes drugs, are reviewed regularly. Using information obtained during these reviews, the committee updates the preferred drug list quarterly.
Once a drug has been reviewed, the committee may reconsider its preferred drug list status if new evidence shows it to be clinically superior or when new cost information is available.
We review drugs when they have:
- Been approved by the U.S. Food and Drug Administration
- Appeared in published studies in peer-reviewed journals
- Been recommended by our providers
We delete medications from the preferred drug list when:
- The U.S. Food and Drug Administration removes them from the market
- Significant safety or effectiveness concerns are raised
- A drug with significantly improved effectiveness or reduced toxicity becomes available
- Removal of the drug will lead to significant cost savings (assuming alternatives with better value exist)
- There is little to no use of the product
- The product becomes available over the counter
Getting Prior Approvals
At HealthPartners, more than 1,500 drugs on our preferred drug list are eligible for payment without any review. Fewer than 3 percent of all prescriptions written for our members require doctors to get prior approval before prescribing them.
The prior approval process helps to maintain the overall value of the preferred drug list. New medications can provide significant advantages, but sometimes they provide very little benefit at a much greater cost than existing medications. There is also less experience with these new products, and the long-term safety is less well known. Advertising by pharmaceutical companies can help increase the demand for these products. The prior approval system helps us make sure that these newer and more costly medications are used only in situations where they really do provide additional benefits. This helps us keep down the costs for everyone.
Doctors requesting prior approval for a particular drug fax us a coverage request on the patient's behalf. Pharmacy Services reviews the request during business hours, generally within one to two hours of receiving it. If the request is approved, we immediately enter approval information into the pharmacy billing system to allow any staff or network pharmacy to process the prescription for the member's pharmacy benefit. If the request is not approved, we notify the provider of the reason and the recommended alternative drug(s).
Step-therapy Drugs (ST)
Step-edit helps assure the appropriate use of medications and can simplify the request process. A specific medication must be tried prior to using step-edit medications. The preferred drug list lists specific step-edit criteria.
If a claim for the required medication is in our pharmacy database (a previous prescription claim from HealthPartners), then the step-edit medication will be processed (there is no need for approval from HealthPartners Pharmacy Customer Service). If a record of the required medication is not available, then the prior authorization process should be followed (a request form needs to be submitted to HealthPartners Pharmacy Services).
Physician-edits (MD)
Certain medications are reserved for a specific group of providers as listed in the preferred drug list. Provider edits help ensure appropriate medications use by limiting certain medications to providers with expertise in their use. The preferred drug list details specific physician-edits. Claims from these providers are processed automatically without needing approval. Claims from other providers are subject to limits as described in the preferred drug list. Exceptions to physician-edits can also be requested by providers.
Quantity Limits (QL)
Quantity limits help ensure the appropriate use of medications, and are specified in the preferred drug list.
Quantity limits are applied for safety reasons (such as limiting products containing acetaminophen to maximum safe limits) and for cost reasons (such as promoting fewer tablets per day for medications that are usually given once-daily). Exceptions (needing a greater quantity) can be requested by providers.
Age-edits (AGE)
Age-edits help assure the appropriate use of medications and can simplify the request process for some medications. Age-edit medications are available without restrictions for patients within specific age groups. Age criteria are listed in the preferred drug list. Patients outside of the specified age group need to meet specific criteria before the medication is approved, and need to use the prior authorization process to submit this information.
Getting Drugs Not Listed on the Preferred Drug List
Ninety-five percent of prescriptions written for HealthPartners members are for preferred drugs. But what happens if your doctor wants you to have a medication that isn't one of the 1,500 drugs on the preferred drug list? What happens if you've already tried a preferred medication and it didn't work for you? Or what if you're a new member and want to continue with a medication you had before you joined HealthPartners, and it's not on our preferred drug list?
It's simple: Your doctor can submit a request for preferred drug list exception. The review process is quicktypically within an hour or two. Decisions are made on case-by-case basis. To help make sure you get the right drug for your condition, our medical reviewers look at information from your doctor and at such things as:
- Diagnosis
- Preferred products that have already been tried
- Evidence of efficacy
- Medical necessity
Appeals Process
If coverage for a particular drug has not been approved, both you and your doctor have the option to appeal that decision.
Members may contact HealthPartners Members Services for information on how to initiate an appeal.
Physicians may contact Pharmacy Services by calling 952-883-5813, option 2, or faxing us at 952-883-5875. Appeals should include any pertinent information not included with the original request. A HealthPartners medical director reviews these appeals within two to three working days. The medical director may request additional information from the requesting physician and may consult with specialty practitioners. An expedited review can be requested.
If the decision is reversed, we inform the requesting physician and enter approval information into the pharmacy billing system so the prescription can be processed. If the decision is upheld, we notify the provider of the reason for the non-approval and any alternative(s) if pertinent.
* Known as the Formulary for Medicare customers.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Preferred Drug List Updates
Changing with the times
Things change quickly in the pharmaceutical field as new and better medications are being developed every day. The preferred drug list is always changing too. Take a moment and check out the most recent updates.
|
|
|
|
|
|
|
|
|
|
Search Our Preferred Drug List
See for yourself
It's quick and easy. Find your medication, and maybe a few alternatives, by
browsing
through the preferred drug list.
|
|
|
|
|
|
|
