3.16 ADHS/DBHS Drug List
3.16.3-A. How is the Medication List used to access
3.16.3-B. Prior authorization
3.16.3-C. How can the Behavioral Health
Providers have input?
The Arizona Department of Health Services/Division of
Behavioral Health Services (ADHS/DBHS) maintains an approved list of
federally reimbursable medications, referred to as the ADHS/DBHS Drug List that must be adopted by the
Regional Behavioral Health Authorities’ (RBHAs’)
and utilized as their drug lists for TXIX/XXI members. The ADHS/DBHS Behavioral Health
Drug List promotes the availability of safe, efficacious and cost-effective medications for eligible
members. Medications not included in the drug list may be covered for Title XIX/XXI members when they are medically necessary, cost effective and federally and state reimbursable. ADHS/DBHS may add, delete
or change medications on the list based on recommendations from the ADHS/DBHS
Pharmacy and Therapeutic (P&T) Committee.
Definitions for terms are located online at
http://www.azdhs.gov/bhs/definitions/index.php. The following terms are referenced in this section:
ADHS/DBHS Drug List
Medicare Advantage Prescription Drug Plan (MA-PD)
Prescription Drug Plan (PDP)
RBHA Drug List
Third Party Liability
How is the Behavioral Health Drug List used to access medications?
To ensure coverage of medications through the RBHA, providers must utilize the
ADHS/DBHS Drug List.
third party private insurance coverage other than Medicare Part D,
have access to behavioral health medications on the private
insurer's health plan's drug list. If the prescribed medication is not included on the health plan’s
private insurer's health plan's drug list, the prescriber shall
submit a prior authorization request for coverage of the medication
to the private insurer. If the request is denied, the prescriber
must assist the member in submitting an appeal to the private
insurer for the medication. RBHAs shall cover medically necessary
federally reimbursable behavioral health medications for persons who
are Title XIX/XXI and have been determined SMI, when the private
insurer refuses to approve the request or appeal for a medication
listed on the
ADHS/DBHS Drug List.
Medicare eligible members, including persons who are dually eligible for Medicare (Title XVII) and Medicaid (Title XIX), shall receive there prescription medications from the Medicare Part D prescription drug benefit through Medicare Prescription Drug Plans (PDPs) or Medicare Advantage Prescription Drug Plans (MA-PDs). Prescription drug coverage for Medicare eligible members must be obtained through the member’s Medicare Part D benefit.
T/RBHAs shall not require prior authorization processes for medications
that have been approved for payment under Medicare Part B plans, and
will specify this information and associated procedures in their
provider manual policies.
Federal and State laws prohibit the use of AHCCCS monies to pay for Medicare Part D medications, including cost sharing. There may be an occasion when a behavioral health member’s prescribed drug is not available through his/her Part D benefit. The RBHAs and/or behavioral health providers must submit a prior authorization request for the medication to the Medicare Part D Plan. If the request is denied, the prescriber must assist the member in submitting an appeal to the Medicare Part D Plan and/or CMS for the medication. RBHAs must provide information to their subcontracted providers indicating whether the RBHA is included as a network provider for a Medicare Advantage Plan that provides a Medicare Part D benefit.
ADHS/DBHS requires the RBHAs to utilize prior authorization
processes for coverage of medications indicated in the ADHS/DBHS Drug List
with a PA requirement. (See
ADHS/DBHS Drug List and Prior Authorization Guidance Documents webpage.)
The RBHAs must utilize the ADHS/DBHS prior authorization criteria to evaluate submitted prior authorizations.
Gila River Behavioral Health Services does not require prior authorization for psychiatric medications. Prior authorization criteria change requests may be submitted to the ADHS/DBHS Chief Medical Officer for review at the next ADHS/DBHS P&T Committee meeting.
How can the Behavioral Health Providers have input?
to the ADHS/DBHS Behavioral Health Drug List
To propose additions, deletions, or changes
ADHS/DBHS Drug List, a behavioral health
professional shall submit a written request
to the T/RBHA Chief Medical Officer or designee:
The RBHA will request the proposed action as an agenda item to be discussed at the next Pharmacy and Therapeutics Committee.
Requests for additions must include the following information:
requested (trade name and generic name, if applicable);
- Dosage forms,
strengths and corresponding costs of the medication requested;
for use (including pharmacological effects, therapeutic uses of
the medication and target symptoms);
of the medication over currently available products listed on
the drug list (including any relevant research findings if
effects reported with the medication;
monitoring requirements; and
- For deletions, a detailed summary of the reason(s) for requesting the deletion.
The following citations can serve as additional resources for this
ADHS/DBHS Drug List
Last Revised: 7/31/2015