Formulary Guidelines

Covered Medications
Medically necessary oral dosage forms and strengths of drugs listed in the formulary are eligible for coverage unless specified otherwise. Medications listed in the formulary with over-the-counter (OTC) equivalents are covered for Medi-Cal members only unless otherwise specified. OTCs are not a covered benefit for the Healthy Families and Healthy Kids programs. A prescription written by a licensed prescriber is required for reimbursement of OTC medications. All OTC claims should be submitted with the prescriber's license number. OTC prescriptions must be filed and prescription containers labeled in accordance with legend prescription requirements.

Copayments
Medi-Cal Program
All prescriptions for Medi-Cal members must be dispensed without a member co-payment. Pharmacies should not fill non-formulary prescriptions for cash payment in place of the prior authorization process. If a prior authorization request is denied, the pharmacy is encouraged to discuss alternate Formulary medications with the prescribing provider and obtain a replacement prescription.

Healthy Families and Health Kids Programs
Healthy Families and Healthy Kids members are required to pay a $5.00 co-payment for most prescriptions.

There is a $250.00 combined medical and pharmacy, annual co-payment maximum per family for each benefit year. The benefit year is from July 1 through June 31. Once the member's family co-payment maximum has been met, an indicator will be set on the member's eligibility file, which will waive the co-payment for the remainder of the benefit year.

Authorization and Claim Processing Service
MedImpact is the pharmacy benefit management organization that processes authorizations and provides on-line claim adjudication services for Santa Clara Family Health Plan. All authorization requests and claims reimbursement requests for medications dispensed through a pharmacy should be submitted to MedImpact. For additional information regarding obtaining authorization or on-line claim submission, please contact the MedImpact Customer Care Center at 1-800-788-2949.

Generic Medications
The appropriate use of generic drugs is one method of providing cost-conscious drug therapy. Generic drugs should be prescribed and dispensed when an AB-rated generic drug is available. Prior Authorization is required for brand necessary prescriptions of drugs when AB-rated generics are available. If generic availability is a problem, please contact the MedImpact Customer Care Center for assistance at 1-800-788-2949.

Brand Drugs Exempt from Mandatory Generic Substitution Requirements Certain drugs may be dispensed as a brand medication without prior authorization. These drugs are specified in the Formulary.

Maintenance Drugs
A 90 to 100 day maintenance supply is covered for oral dosage forms of specified drugs as listed in the Formulary. Injectable dosage forms are not eligible for maintenance supply coverage.

Drugs Administered by The Prescribing Provider
The prescribing provider must bill for any drug supplied by the prescriber, including injectable antineoplastic medications. Claims for drugs that the member does not obtain through a pharmacy must be submitted by the prescribing provider directly to Santa Clara Family Health Plan.

Compounded Medications
Medications that require compounding are eligible for coverage when at least one of the ingredients is a prescription legend drug or a covered prescription non-legend drug. However, prior authorization is required when the drug cost is greater than $50. Compounded medications must be submitted for on-line adjudication using the NDC of the highest cost ingredient and compound code of "2" to identify the claim as a compound.

Investigational Drugs
Medications that have not been approved by the U.S. Food and Drug Administration are not eligible for coverage.

Off-Label Use of Prescription Drugs
Prior authorization is required for coverage of drugs prescribed for off-label usage. It is the prescribing provider's responsibility to provide documentation that the following criteria are met for authorization of off-label drug usage:

• The drug must be approved by the FDA; and
• The drug must be on the Formulary and prescribed by a participating provider for either a life-threatening condition or for a chronic and seriously debilitating condition and must be medically necessary to treat that condition; and
• The drug must be recognized for treatment by either the American Medical Association Drug Evaluations, the American Hospital Formulary Service Drug Information, the U.S. Pharmacopiea, or two articles from major peer-review journals that do not have contradicting data supporting the proposed use as safe and effective.

Price Restrictions
Prior Authorization is required for any claim for non-compound drugs with a dollar amounts greater than $500. Claims greater than $500 will be reviewed for correct claim submission, dosing and pricing.

Procedures for Prior Authorization
Santa Clara Family Health Plan encourages providers to prescribe formulary medications whenever possible. However, when a provider prescribes a non-formulary drug because formulary alternatives are not appropriate, a Prior Authorization Request Form (PA) must be completed by the pharmacy and faxed to MedImpact.

Whenever medically appropriate, the pharmacy should work with the prescribing provider to identify an alternative Formulary medication to eliminate the need to submit a PA. Prior authorization is not required if the prescribing provider issues a prescription for an alternate Formulary medication.

FAX PA requests to MedImpact at 1-858-790-7100

Prior authorization hours are Monday through Friday 6:00a.m. to 6:00 p.m. excluding holidays. Providers may call the MedImpact Customer Care Center at 1-800-788-2949 for assistance with any authorization or claim issues 24/7.

Providers may not request out-of-pocket payment from Santa Clara Family Health Plan members for medically necessary prescription medications instead of submitting a PA request. To expedite dispensing, please indicate on the authorization that the request is urgent or call the MedImpact Customer Care Center for assistance. Also, Santa Clara Family Health Plan will cover a 5 days supply for any medication when the dispensing pharmacist feels that the member's need is emergent.

All fields on the Santa Clara Family Health Plan PA form must be completed for expeditious review of the request, including the following:

• Member Identification: name and Santa Clara Family Health Plan ID number
• Pharmacy Identification: name, fax and phone number
• Prescribing Provider's Identification: name, phone number, medical specialty
• Medication Information: drug name, strength and NDC number
• Treatment Plan: Quantity (monthly quantity or quantity for a stated days supply), days supply and expected duration of therapy
• Formulary Alternative Medications: The pharmacy should list any alternative medications that are on the Formulary. The prescribing provider has the option to issue a new prescription instead of completing the PA which can expedite dispensing. A list of alternative Formulary medications may be available from the MedImpact on-line claim message for most medications that require prior authorization. Otherwise pharmacists should refer to the Drug Formulary categorized by therapeutic classes for formulary alternatives
• Medical justification: A narrative explanation of the medical necessity for use of the selected drug. This information may be completed by the prescribing provider.
• Diagnosis - for the requested drug and all other relevant diagnoses
• Other drugs tried/failed: a list of drugs that the member has tried and failed previously for this indication, the date of trial, and the reason for failure of the trial
• Supporting lab values/documentation: (e.g. C&S reports, lipid panels, chemistry panels, weight/height or growth chart, etc.)
• Specialty consult recommendations: including medical procedures (e.g. psychiatry / gastroenterology consultation, etc. or gastro-endoscopy report [EGD], etc.)

The Prescriber and pharmacist must complete all requested information in their appropriate sections of the PA form to avoid unnecessary delays in processing. MedImpact may return or defer incomplete or illegible forms to the pharmacy for clarification or additional information. When this happens, the providers will need to resubmit the prior authorization with the requested information.

When a PA request is approved, MedImpact will fax notification to the pharmacy and physician via a fax-back PA response. The pharmacy may adjudicate the claim on-line as directed by the PA fax-back message from MedImpact. A prior authorization number is not required. If a PA request has been approved but the claim continues to reject, please call the MedImpact Customer Care Center for further assistance at 1-800-788-2949.

Emergency Supplies Override Process

The emergency supply process may be used during regular business hours, holidays and weekends when a PA approval can not be obtained or a PA request is still under review but the patient's clinical situation necessitates immediate therapy.

Pharmacies may call the MedImpact Customer Care Center to request an emergency supply override at 1-800-788-2949. The emergency supply policy guarantees reimbursement for up to a 5-day medication supply and a maximum quantity of "25". The pharmacy must submit a PA and receive approval for reimbursement of any further supply.

This process is only available when needed and utilization will be monitored and audited. The MedImpact Customer Care Center is available 24/7.

Formulary Updates
Santa Clara Family Health Plan will issue periodic notifications of revisions to the Formulary as they occur through a fax broadcast to all contracted pharmacies and physicians. A list of commonly prescribed drugs and their respective formulary status with relevant prior authorization criteria for coverage can be accessed with a subscription to www.epocrates.com.

Formulary Addition Request
The Santa Clara Family Health Plan Pharmacy and Therapeutics Committee meets bimonthly to review Formulary related issues. Participating physicians and pharmacists are welcome to submit requests for the addition of medications to the Santa Clara Family Health Plan Formulary using the non-formulary review request form.
Santa Clara Family Health Plan
Pharmacy and Therapeutics Committee
210 E. Hacienda Avenue
Campbell, CA 95008
ATTN: Clinical Pharmacist

For additional information regarding the Santa Clara Family Health Plan pharmacy coverage and for assistance with Santa Clara Family Health Plan policies or procedures, please contact our Clinical Pharmacist at 408-376-2000.