Pharmacy Medical Necessity Determination
All medications are subject to Medical Necessity review. We focus our reviews on those drugs that have a high potential for inappropriate use, high-cost medications, those that have narrowly defined federal Food and Drug Administration (FDA)-approved indications, and medications that have a significant interaction risk if taken with other agents. Medical Necessity criteria and guidelines are established and approved by physicians and pharmacists. These external oversight committees assure that our Medical Necessity criteria and guidelines reflect community prescribing standards for the appropriate medication prescribed for members.
Programs that make up the Medical Necessity determination include Drug Dispensing Limitations, Drug Utilization Review (DUR) and Prior Authorization.
- Drug Dispensing Limitations
Certain prescription medications have specific dispensing limitations for quantity, age, gender and maximum dose. To arrive at these quantity or safety limits, Horizon NJ Health follows recommendations by the FDA, coupled with our analysis of prescription dispensing trends and standard clinical guidelines. These dispensing limitations are drug or class specific and are designed to provide a safe and effective amount of medication to the member. The list is subject to change and will be periodically updated. If a prescriber feels that a drug is medically necessary outside of the dispensing limitations, an exception can be requested by contacting the Horizon NJ Health Pharmacy Department at 1-800-682-9094 or by completing the form below and faxing to the number noted on the fax form. If additional information is required, Horizon NJ Health staff will attempt to obtain this information from the prescribing physician.
- Drug Utilization Review (DUR)
Since a member can be seen by different doctors and obtain medication through a variety of pharmacies, DUR edits help prevent potential drug interactions, therapeutic duplication, and other drug safety considerations. Our online claims processing computer system allows immediate review and verification of eligibility, prescription drug coverage, drug-to-drug interactions and restrictions.
- Prior Authorization (PA)/Medical Necessity Determination (MND)
Certain drugs require Prior Authorization (PA)/ Medical Necessity Determination (MND) before coverage is approved. The PA/ MND process is designed to assure that only prescription medications that are medically necessary and clinically appropriate are approved for coverage. PA/MND also encourages appropriate utilization of certain prescription drugs, promotes generally accepted treatment protocols, actively monitors prescription drug use that may have serious side effects and helps keep the cost of prescription drug therapy affordable.
A Horizon NJ Health committee, the Pharmacy and Therapeutics Committee, is made up of practicing physicians, pharmacists and Horizon NJ Health health care professionals. The Committee establishes PA/MND criteria for medications after evaluating the most current published, peer-reviewed medical literature, expert medical opinion, specialty society recommendations and FDA-approved labeling information. Only after PA/MND criteria are met can a prescribed drug be authorized and covered.
Prior authorization criteria are listed within the policies found in the Medical Policy Manual.
The PA and MND programs also include programs to promote generic use. If there is not a medically appropriate reason for using a brand name drug for which a generic is available, the patient will be required to try a generic drug first before a brand name equivalent of the same medication would be considered for medical necessity.
During the course of a patient’s treatment, there may be circumstances where a brand name drug should be dispensed, even though a generic equivalent or generic alternative is available. In these cases, PA/MND can be requested for the brand name drug. Such PA/MND requests will be reviewed promptly by a qualified clinical reviewer/physician through the plan’s PA/MND process.
When pharmacists enter the requested prescription into the point-of-sale system, they are advised when PA/ MND is required before that particular brand name drug may be covered and dispensed.
In most instances, if a generic can be taken, then PA/ MND is not required.
If you feel that a non-formulary drug is medically necessary due to ineffectiveness or intolerance to previously tried formulary alternatives, PA/MND can be requested for the non-formulary drug. Such PA/MND requests will be reviewed promptly by a qualified clinical reviewer/physician through the plan’s PA/MND process.
Step therapy requires that one or more “prerequisite” first step drugs be tried before progressing to second step drugs. First step medications and the corresponding second step medications are FDA-approved and are used to treat the same conditions.
During the course of a patient’s treatment, there may be circumstances where a second step medication should be tried without trying a first step medication. In these cases, PA/MND can be requested for the second step drug. Such PA/MND requests will be reviewed promptly by a qualified clinical reviewer/physician through the plan’s PA/MND process.
Medications requiring step therapy are listed within the Formulary Guide
In order to obtain prior authorization or for paper copies of any pharmaceutical management procedure, please contact the Horizon NJ Health Pharmacy Department at 1-800-682-9094. In addition, prior authorization can be requested by filling out the appropriate authorization form and faxing to the fax number located on the form. If additional information is required, Horizon NJ Health staff will attempt to obtain this information from the prescribing physician.