2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

PharmacyOnce the request has been received, a letter is sentto the requesting provider acknowledging receipt ofthe request and stating when it will be reviewed.Additional information may be solicited to supportthe request.Requesting providers may be invited to attend theP&T Committee meeting and present their case forthe addition of a drug, although attendance is notmandatory.A Presbyterian pharmacist reviews all requests andprepares a written review of the drug for the P&TCommittee. Formulary changes and the rationale ofthe changes are communicated to all appropriateparties through memorandum or newsletter.Committee actions regarding deletions take effect60 days following the decision. Additions areeffective 30 days following the decision. Anyremoval of a formulary drug is associated with all ofthe following procedures:Identify members who are currently on theagentNotify the member of the change in benefitwith at least a 60-day noticeEnsure that the affected member hascontinued coverage of the drug during the 60-day notification periodPresbyterian providers may obtain a copy of theformulary by downloading the formulary fromhttp://www.epocrates.com/, or from the pharmacypage at https://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.Formulary changes are communicated to providersfollowing each P&T Committee meeting.Pharmacy Prior Authorization ProcessPresbyterian’s pharmacy prior authorizationprocess includes intake, evaluation, decisionmaking, and response to the requesting provider.An automated prior authorization system is usedwhere providers can submit pharmacy priorauthorization requests online through myPRES orby fax. Protocols with criteria are built into thesystem, so in many instances providers receive thedecision as soon as they finish submitting therequired information. To access myPRES, go tohttps://mypres.phs.org.Providers can also request prior authorization ofcovered services through myPRES. This processensures appropriate and timely services toPresbyterian members.Non-formulary requests are evaluated by thePharmacy Services Department for medications notlisted in the current Presbyterian formularies,requests for drugs for which Presbyterian requiresprior authorization, and for quantities which are inexcess of those defined by the product line benefitdescription documents.Determinations are made on a timely basis asrequired by the urgency of the situation, inaccordance with sound medical principles andregulatory requirements.Our Pharmacy Services Department is under thedirect supervision of at least one full-time clinicalpharmacist who is accountable to a medicaldirector.8-112014 Practitioner and Provider Manual - Ver. 3