Statewide Preferred Drug List Information
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The Department of Human Services ("the department") maintains a
Statewide Preferred Drug List (PDL) to ensure that Medical Assistance (MA) program beneficiaries in the Fee-for-Service (FFS) and HealthChoices/Community HealthChoices Managed Care Organization delivery systems have access to clinically effective pharmaceutical care with an emphasis on quality, safety, and optimal results from the drugs that are prescribed for them.
When considering medications from a class included on the Statewide PDL for MA beneficiaries, providers should try to utilize drugs that are designated as preferred. Drugs designated as non-preferred on the Statewide PDL remain available to MA beneficiaries when determined to be medically necessary through the prior authorization process.
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What is the Statewide Preferred Drug List?
The Statewide PDL is a list of medications that are grouped into therapeutic classes based on how the drugs work or the disease states they are intended to treat. The department's Pharmacy and Therapeutics (P&T) Committee, which is comprised of external physicians, pharmacists, consumer representatives, and voting members from each of the HealthChoices and Community Health Choices MCOs, recommends therapeutic classes to include on the PDL, preferred or non-preferred status for the drugs in each class, and corresponding prior authorization guidelines for each class. The committee's recommendations are approved by the secretary of the Department of Human Services (DHS) prior to implementation.
The Statewide PDL is therapeutically based. The department's P&T Committee considers new medical literature and national treatment guidelines when recommending preferred or non-preferred status for drugs on the Statewide PDL. The committee's recommendations are based on the clinical effectiveness, safety, outcomes, and unique indications of all drugs included in each PDL class. When drugs within a class are clinically equivalent, the committee considers the comparative cost-effectiveness of the drugs in the class.
The Statewide PDL applies to beneficiaries who receive their pharmacy benefits through the FFS delivery system and to beneficiaries who receive their pharmacy benefits through one of the HealthChoices/Community HealthChoices MCOs.
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Non-Preferred Drugs and Preferred Drugs with Clinical Prior Authorization
All non-preferred drugs on the Statewide PDL remain available to MA beneficiaries when found to be medically necessary. All drugs designated as non-preferred on the Statewide PDL require prior authorization through the beneficiary's pharmacy benefits provider.
Some preferred drugs on the Statewide PDL require a clinical prior authorization. All preferred drugs that require clinical prior authorization remain available to MA beneficiaries when found to be medically necessary. All drugs designated as preferred with clinical prior authorization on the Statewide PDL require prior authorization through the beneficiary's pharmacy benefits provider.
Prior authorization requests for beneficiaries who receive their pharmacy benefits through a HealthChoices or Community HealthChoices MCO should be directed to the applicable MCO. Prior authorization requests for beneficiaries who receive their pharmacy benefits through the Fee-for-Service delivery system should be directed to the DHS Pharmacy Services division.
The prior authorization guidelines for drugs and drug classes included on the Statewide PDL apply to beneficiaries who receive their pharmacy benefits through the FFS delivery system and to beneficiaries who receive their pharmacy benefits through one of the HealthChoices/Community HealthChoices MCOs. The guidelines are available on the department's
Pharmacy Prior Authorization Clinical Guidelines website under "Statewide PDL Prior Authorization Guidelines."
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New Drugs to Market in Statewide PDL Classes
The Statewide PDL will be updated annually, but that will not preclude beneficiaries from getting new drugs that come to market as long as they meet CMS criteria for a Medicaid covered drug. Drugs that fall into a class on the Statewide PDL are generally designated as non-preferred until they are reviewed by the P&T committee. These drugs remain available to Medicaid beneficiaries through the prior authorization process.
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The Statewide PDL is not the same as the formularies that are commonly used by commercial insurers. A formulary is a list of all drugs that are covered by a payer. Payers cover drugs that are listed on their formularies, and drugs that are not included on their formularies are generally not covered.
In Medicaid, the list of covered drugs is determined by CMS and is based on whether the manufacturer agrees to pay the federally mandated Medicaid drug rebate. Medicaid agencies must make payment for all Medicaid covered drugs when they are medically necessary. Medicaid programs and Medicaid MCOs may manage the list of covered drugs through a Preferred Drug List (PDL) and/or prior authorization.
The Statewide PDL includes only a subset of all Medicaid covered drugs. It is not an exclusive list of drugs covered by Medicaid and includes approximately 35% of all Medicaid covered drugs. All Medicaid covered drugs are available to beneficiaries when medically necessary regardless of the drugs' inclusion on the Statewide PDL.
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Drugs Not Included on the Statewide PDL
Medicaid-covered drugs in therapeutic classes that are not included in the Statewide PDL remain covered drugs for beneficiaries. Some drugs that are not included on the Statewide PDL may require clinical prior authorization by the beneficiary's MCO or FFS.
Less than 2% of Medicaid covered drugs that are not included on the Statewide PDL require clinical prior authorization in the FFS delivery system. The list of these drugs may be found on the department's
Pharmacy Prior Authorization Clinical Guidelines website under "Fee-for-Service Non-PDL Prior Authorization Guidelines".
Additional information regarding prior authorization of drugs not included on the Statewide PDL for beneficiaries who receive their pharmacy benefits from one of the HealthChoices or Community HealthChoices MCOs is available directly from each MCO.
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Quantity Limits
Some Medicaid covered drugs (both those that are included on the Statewide PDL and those that are not included on the Statewide PDL) also require prior authorization if the prescribed quantity and/or dose exceeds the dose that is approved by the FDA for each medication. The department maintains
a list of drugs that are subject to quantity limits or daily dose limits for beneficiaries in the FFS delivery system.
Additional information regarding quantity limits for beneficiaries who receive their pharmacy benefits from one of the HealthChoices or Community HealthChoices MCOs is available directly from each MCO.
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Change Healthcare
The Department contracts with Change Healthcare to provide consultation and support for the
Statewide PDL.
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