Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition


Section 3.16 ADHS/DBHS Drug List

3.16.1 Introduction
3.16.2 Terms
3.16.3 Procedures
3.16.3-A. How is the Medication List used to access medications?
3.16.3-B. Prior authorization
3.16.3-C. How can the Behavioral Health Providers have input?

3.16.4 References

3.16.1 Introduction
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.

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3.16.5 Definitions
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

Behavioral Health Professional

Dual Eligible

Medicare Advantage Prescription Drug Plan (MA-PD)

Prescription Drug Plan (PDP)

Prior Authorization

RBHA Drug List

Third Party Liability

3.16.3 Procedures

3.16.3-A. 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.

Members with 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.

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3.16.3-B: Prior authorization
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.

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3.16.3-C: How can the Behavioral Health Providers have input?
Changes to the ADHS/DBHS Behavioral Health Drug List
To propose additions, deletions, or changes to the 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.

Additions:
Requests for additions must include the following information:

  • Medication requested (trade name and generic name, if applicable);
  • Dosage forms, strengths and corresponding costs of the medication requested;
  • Average daily dosage;
  • Indications for use (including pharmacological effects, therapeutic uses of the medication and target symptoms);
  • Advantages or disadvantages of the medication over currently available products listed on the drug list (including any relevant research findings if available);
  • Adverse effects reported with the medication;
  • Specific monitoring requirements; and
  • For deletions, a detailed summary of the reason(s) for requesting the deletion.

3.16.4 References
The following citations can serve as additional resources for this content area:

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3.16 ADHS/DBHS Drug List
Last Revised: 7/31/2015
Effective: 7/31/2015

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