HUSKY MCO Pharmacy Formulary Review

 Summary

The 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:

1.      Complete Formulary Review

·   Mercer’s 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.

2.      Formulary Additions Review

·   No review by DSS is required when an MCO adds a prescription drug to its formulary.

3.      Formulary Deletions Review

·   An 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.

Note 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.