Pharmacy Medical Necessity Determination

Ensuring Prescription Medicines are Medically Necessary

Some medicines require review to help ensure patient safety. We call this review a medical necessity determination (MND). Medicines that require a MND, or are medically necessary, include ones that:

  • Can be used incorrectly
  • Can be dangerous if taken with other medicines
  • Have narrowly defined Food and Drug Administration (FDA)-approved indications
  • Are high cost

We leverage physicians and pharmacists, who are part of external oversight committees, to determine what’s medically necessary. This helps ensure that our medical necessity criteria and guidelines reflect community-prescribing standards.

To help determine what’s medically necessary, we have several programs, including Drug Dispensing Limitations, Drug Utilization Review (DUR) and Prior Authorization.

Drug Dispensing Limitations

Some prescription medicines can only be used in certain doses based on age, sex and other factors. Dispensing limitations are set based on types of medicines and safety standards. We follow recommendations of the FDA along with our analysis of prescription dispensing trends and clinical guidelines. Dispensing limitations are updated as needed.

If a prescriber feels that a drug is medically necessary outside of the dispensing limitations, an exception can be requested by calling our Pharmacy Department at 1-800-682-9094 or completing and faxing the appropriate form below to the number noted. If more information is required, we will contact the prescribing physician.

Drug Utilization Review (DUR)

Because a member can be seen by different doctors and get medicine from different pharmacies, DURs help prevent potential drug interactions, over-usage, and other drug safety considerations. Our system allows immediate review and verification of eligibility, prescription drug coverage, drug-to-drug interactions and restrictions.

Prior Authorization

Certain drugs require Prior Authorization/Medical Necessity Determination (PA/MND) review before coverage is approved. The PA/MND process helps ensure that only prescription medicines that are needed and clinically appropriate are approved for coverage. PA/MND also encourages the right use of certain prescription drugs, promotes standard treatment protocols, monitors prescription drug use that may have serious side effects and helps keep the cost of prescription drugs affordable.

Our Pharmacy and Therapeutics (P&T) Committee is made up of physicians, pharmacists and Horizon NJ Health professionals. The committee establishes PA/MND criteria for medicine after evaluating current published, peer-reviewed medical literature, expert opinions, specialty society recommendations and FDA-approved labeling information. Only this review can a prescribed drug be authorized and covered.

PA/MND includes other programs to help ensure medical necessity:

  • Generic Substitutions
    A patient must try a generic drug before an equal brand name drug can be considered medically necessary. When pharmacists enter a prescription, they will see if a PA/MND is required before a brand name drug may be covered and dispensed. You can ask for use of a brand name drug to be reviewed by a clinical reviewer/physician through our PA/MND process.
  • Non-Formulary Medications
    PA/MND can be requested and will be reviewed by a clinical reviewer/physician if you feel that a non-formulary drug is medically necessary due to ineffectiveness of or intolerance to formulary alternatives.
  • Step Therapy
    Step therapy requires that one or more drugs be tried before progressing to second-step drugs. These “first” - and corresponding “second”-step medicines are FDA-approved and are used to treat the same conditions. There may be times where a second-step medicine should be tried first. In these cases, PA/MND can be requested and will be reviewed by a clinical reviewer/physician through the PA/MND process. Medicines requiring step therapy are listed in the Formulary Guide.

Prior authorization standards are listed in the Medical Policy Manual.

To obtain prior authorization, or for printed copies of any pharmaceutical management procedure, please call our Pharmacy Department at 1-800-682-9094.

Prior authorization can also be requested by filling out the appropriate authorization form below and faxing to the noted number. If additional information is required, we will contact the prescribing physician.