How we develop the Priority Health Medicare approved drug list
The Approved Drug List (formulary) is developed through a rigorous process to ensure that your prescription drug coverage is safe and effective.
The Pharmacy and Therapeutics (P&T) Committee
This committee meets six times a year to create and maintain programs that promote rational, safe and effective drug use based on each individual's needs. Its members include representatives from the Priority Health Pharmacy and Medical departments and actively practicing physicians and pharmacists.
Approving drugs
The P&T Committee uses specific, medically accepted guidelines to determine whether a drug on the approved drug list (formulary) may be approved for a health plan member. The Committee assesses certain criteria, including:
- Scientific evidence and standards of practice
- Peer-reviewed medical literature
- Well-established clinical practice guidelines
- Pharmacoeconomical studies (therapeutic value per dollar)
- Therapeutic advantages (safety and effectiveness)
Medication Therapy Management (MTM) program
Several pharmacy-related programs are managed by the P&T Committee. One of these programs, called the Medication Therapy Management (MTM) Program, helps make sure that the approved drugs prescribed to certain members are used appropriately.
MTM Programs are limited to enrollees who meet specific criteria, such as having multiple chronic diseases (asthma, diabetes, cardiovascular disease, dyslipidemia and hypertension). These people are taking multiple medications and are likely to spend at least $4,000 a year on their drugs. By monitoring their medication use and reporting adverse events such as harmful drug interactions, the MTM Program helps improve therapeutic outcomes.
The MTM program is not considered a benefit of membership in our plans. Eligibility is determined by our Disease Management staff under guidance from the P&T Committee. You should contact us if you want more information about Medication Therapy Management.
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Drug utilization review
The P&T Committee also oversees, reviews and approves Priority Health's Drug Utilization Review (DUR) program, which uses quality assurance measures to determine the appropriate use of medications. The DUR program measures drug use data against predetermined standards and monitors (at minimum) the following items:
- Therapeutic appropriateness
- Over/under-utilization
- Appropriate use of generic drugs
- Therapeutic duplication
- Drug-disease contraindications
- Drug-drug interactions
- Incorrect drug dosage or duration of drug treatment
- Clinical abuse/misuse
These reviews may be performed on a prospective, retrospective or concurrent basis.
Case management
The Priority Health Pharmacy department works closely with Case Management staff to help members who need assistance managing their chronic or complex acute illness(es). With assistance from pharmacy staff, nurses work with members to review medications in order to avoid drug duplications, drug-to-drug conflicts, drug-to-diagnosis conflicts, drug-to-lab conflicts and guideline conflicts. When appropriate and necessary, nurses contact a member's physician to discuss areas of concern.
Updated: September 30, 2009