2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

PharmacyThe drug must be accepted for use by themedical communityThe drug must provide a cost-effectivealternative for the treatment of the medicalconditionThe drug must not be experimental orinvestigationalRecommendations of national organizations,committees, or specialty societies are stronglyconsideredThe drug is mandated as the result of stateMedicaid mandates or is CMS-mandatedThe committee makes recommendations forchanges to the formularies. The committeedevelops forms to be completed when requestingan addition of a drug to the formularies and definesprocedures and responsibilities for documenting theneed for a formulary addition or replacement.The committee may propose and approve certainmechanisms for approved formulary agents that aredesigned to promote appropriate usage. Thesemechanisms would include but not be limited toPrior authorization by medical criteriaapproved by the committeeStep Edit (a requirement for a trial of anotherappropriate formulary/drug listing agent beforecoverage of the targeted drug)Quantity limits based on manufacturer’srecommended maximum daily dosingThe establishment of suitable educationalprograms for the Presbyterian CentennialCare panel of medical providers andPresbyterian Centennial Care enrollees onmatters relating to drug therapyReview of the use of drugs or drug classes byPresbyterian Centennial Care providers andmembers to detect both underutilization andoverutilization, and recommendations toimprove medically appropriate and costeffectivedrug utilizationReview of adverse drug reactions occurring inthe ambulatory care setting, investigation ofpossible causes, and recommendations tominimize the occurrence of adverse drugreactions, and report of serious adverse drugreactions to the FDA when appropriateParticipation in quality assurance activitiesrelated to the distribution, administration, anduse of medicationsReview and approval of all PresbyterianCentennial Care guidelines and policiesrelated to the use of medicationsReview and Approval of Requests for FormularyChangesAll requests should be documented on the“Request for addition of a drug to the PresbyterianFormulary” form. This is available on thePresbyterian website athttps://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.For assistance, call Presbyterian’s PharmacyServices Department directly at 505-923-5500 oroutside Albuquerque at 1-888-923-5757, using the“Pharmacy” option.8-102014 Practitioner and Provider Manual - Ver. 3