PHARMACY

Pharmacy Program
Kentucky Spirit Health Plan (Kentucky Spirit) is committed to providing appropriate, high quality, and cost effective drug therapy to all Kentucky Spirit members. Kentucky Spirit works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Kentucky Spirit covers prescription medications and certain over-the-counter (OTC) medications when ordered by a Kentucky Spirit physician/clinician. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.

This section provides an overview of the Kentucky Spirit pharmacy program. For more detailed information, please visit our website at www.KentuckySpiritHealth.com.

Preferred Drug List
The Kentucky Spirit Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs the member receives at retail pharmacies. The Kentucky Spirit PDL is continually evaluated by the Kentucky Spirit Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the Kentucky Spirit Medical Director, Kentucky Spirit Pharmacy Program Director, and several Kentucky primary care physicians and specialists.

Pharmacy Benefit Manager
Kentucky Spirit works with US Script to process all pharmacy claims for prescribed drugs. Some drugs on the Kentucky Spirit PDL require a PA and US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager.

Biopharmaceuticals
Kentucky Spirit provides a number of biopharmaceutical products through the Biopharmaceutical Program. Most biopharmaceuticals and injectables billed for more than $250 require a PA to be approved for payment by Kentucky Spirit; however, PA requirements are programmed specific to the drug as indicated in the list provided in the Biopharmaceutical Program document located on the Kentucky Spirit website at www.KentuckySpiritHealth.com.

Prescription Limits
In general, members age 19 and above may get up to four prescriptions per 26 days. No more than three of the four prescriptions may be name brand products, including refills.

Children under 19 years of age may get more than three brand name prescriptions per 26 days. Insulin products (defined by Drug Category Code “I” and route of administration is intravenous, intramuscular, injection, intradermal, or subcutaneous) are exempt from the three name brand prescription limitation. If the member’s three brand prescription limit has been exceeded, and the prescription, in the pharmacist’s professional judgment, is for a life threatening medical condition that, if medication is not dispensed, could result in hospitalization or place the member in jeopardy, the pharmacist can provide additional brand name products.

Children under 19 years of age may get more than four prescriptions per 26 days. Insulin products (defined by Drug Category Code “I” and route of administration is intravenous, intramuscular, injection, intradermal, or subcutaneous) are exempt from the four prescription limitation. If the member has one or more of the following medical conditions the four prescription limitation is not applicable:
 Acute therapy for migraine headaches/acute pain
 Acute infections/infestations
 Bipolar disorders
 Cancer
 Cardiac rhythm disorders
 Chronic pain
 Coronary artery/cerebrovascular disease (advanced arthrosclerotic disease)
 Cystic fibrosis
 Dementia
 Diabetes
 End stage lung disease
 End stage renal disease
 Epilepsy
 Hemophilia
 HIV/AIDS/Immunocompromised
 Hyperlipidemia
 Hypertension
 Major depression
 Metabolic syndrome
 Organ transplant
 Psychotic disorders
 Schizophrenic disorders
 Schizotypal personality disorders
 Supressive therapy for thyroid cancer
 Terminal state of an illness

The four prescription limitation is not applicable for following therapeutic classes/medications:
 Alpha 1-Proteinase
 Alzheimer’s agents
 Antibiotics
 Antipsychotics
 Anti-Parkinson agents
 Anti-Tuberculosis agents
 Anti-Viral medications
 Asthma/COPD agents
 Cancer agents
 Cardiovascular agents
 Clotting Factors/Antiplatelet
 Contraceptives
 Diabetes agents
 Dialysis
 Folic Acid
 Hematopoietic agents
 Large Volume Parenterals
 Lipotropics
 Monoclonal Antibodies
 Multiple Sclerosis agents
 Prenatal vitamins
 Pulmonary Hypertension agents
 Thyroid agents
 Total Parenteral Nutrition
 Transplant agents
 Thalomid
 Xolair

Dispensing Limits
Drugs may be dispensed up to a maximum of 32 days supply for each new prescription or refill. A total of 75% of the days supply must have elapsed before the prescription can be refilled for non-controlled-substance PDL drugs. A total of 85% of the days supply must have elapsed before the prescription can be refilled for controlled substances and narcotic PDL drugs.

Appropriate Use and Safety Edits
The health and safety of our members is a priority for Kentucky Spirit. One of the ways we address patient safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

Additional information about the drugs that are part of the Appropriate Use and Safety Edits can be found in the Appropriate Use and Safety Edits document located on the Kentucky Spirit website at www.KentuckySpiritHealth.com.

Prior Authorizations
Some medications listed on the Kentucky Spirit PDL may require PA. The information should be submitted by the physician/clinician to US Script on the Medication Prior Authorization Form. This form should be faxed to US Script at 1-866-399-0929. This document is located on the Kentucky Spirit website at www.KentuckySpiritHealth.com.

Kentucky Spirit will cover the medication if it is determined that:
1. There is a medical reason the member needs the specific medication.
2. Depending on the medication, other medications on the PDL have not worked.

All reviews are performed by a licensed clinical pharmacist using the criteria established by the Kentucky Spirit P&T Committee. Once approved, US Script notifies the physician/clinician by fax. If the clinical information provided does not meet the coverage criteria for the requested medication Kentucky Spirit we will notify the member and the physician/clinician of alternatives and provide information regarding the appeal process.

Step Therapy
Some medications listed on the Kentucky Spirit PDL may require specific medications to be used before a member can receive the step therapy medication. If Kentucky Spirit has a record that the required medication was tried first the step therapy medications are automatically covered. If Kentucky Spirit does not have a record that the required medication was tried, the member or physician/clinician may be required to provide additional information. If Kentucky Spirit does not grant PA we will notify the member and their physician/clinician and provide information regarding the appeal process.

Quantity Limits
Kentucky Spirit may limit how much of a medication a member can get at one time. If the physician/clinician feels the member have a medical reason for getting a larger amount, he or she can ask for PA. If Kentucky Spirit does not grant PA we will notify the member and the physician/clinician and provide information regarding the appeal process.

Age Limits
Some medications on the Kentucky Spirit PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Gender Limits
Some medications on the Kentucky Spirit PDL may be limited to one gender. These medications have a GL after them on the PDL. These limits are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Gender limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Medical Necessity Requests
If the member requires a medication that does not appear on the PDL, the member of physician/clinician can make a medical necessity request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. Kentucky Spirit requires:
 Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or
 Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or
 Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication.
All reviews are performed by a licensed clinical pharmacist using the criteria established by the Kentucky Spirit Pharmacy and Therapeutics Committee. If the clinical information provided does not meet the coverage criteria for the requested medication Kentucky Spirit will notify the member and the physician/clinician of alternatives and provide information regarding the appeal process.

72-Hour Emergency Supply Policy
State and Federal law require that a pharmacy dispense a 72-hour (3-day) supply of medication to any patient awaiting a PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72-hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call the US Script Pharmacy Help Desk at 1-800-460-8988 for a prescription override to submit the 72-hour medication supply for payment.

Exclusions
The following drug categories are not part of the Kentucky Spirit PDL and are not covered by the 72-hour emergency supply policy:
 Fertility enhancing drugs
 Anorexia, weight loss, or weight gain drugs
 Experimental or investigational drugs
 Immunizations and vaccines (except flu vaccine)
 Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective
 Infusion therapy and supplies
 Oral vitamins and minerals (except those listed in the PDL)
 Drugs and other agents used for cosmetic purposes or for hair growth
 Erectile dysfunction drugs prescribed to treat impotence
 Drugs eligible for coverage under Medicare Part D
 OTC drugs (except those listed in the PDL)

Newly Approved Products
We review new drugs for safety and effectiveness before adding them to the Kentucky Spirit PDL. During this period, access to these medications will be considered through the PA review process. If Kentucky Spirit does not grant PA we will notify the member and physician/clinician and provide information regarding the appeal process.

Over-the-Counter Medications
The Kentucky Spirit PDL covers a variety of OTC medications. A list of covered OTC medications can be found in the Over-the-Counter Medications section of the PDL. Kentucky Spirit PDL OTCs are covered when a member has a prescription from a licensed physician/clinician that meets all the legal requirements for a prescription.

Tobacco Cessation Medications
The following types of tobacco cessation medications will be covered by Kentucky Spirit: generic nicotine replacement products (gum, lozenges, and patches), Bupropion Hydrochloride, and Varenicline Tartrate (Chantix). A physician/clinician prescription will be required for all tobacco cessation medications. Each prescription will count toward the monthly limit.

Kentucky Spirit authorizes benefits for tobacco cessation medications for the purpose of supporting members who are trying to quit tobacco use with the temporary assistance of nicotine replacement therapy. It is expected that utilization of these products will be in accordance with medical standards of practice, FDA guidelines, and manufacturers’ recommendations which generally limit product use to approximately 12 weeks.

Generic Drugs
When generic drugs are available, the brand-name drug will not be covered without prior Kentucky Spirit authorization. Generic drugs have the same active ingredient, work the same as brand-name drugs, and have lower co-payments. If the member and the physician/clinician feel a brand-name drug is medically necessary, the physician/clinician can ask for PA. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If Kentucky Spirit does not grant PA we will notify the member and the physician/clinician and provide information regarding the appeal process.

The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Amiodarone, Carbamazepine, Clozapine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-thyroxine, Lithium, Phenytoin, Procainamide, Propafenone, Theophylline, Thyroid, Valproate Sodium, Valproic Acid, and Warfarin.

Filling a Prescription
Members can have prescriptions filled at a Kentucky Spirit network pharmacy. If a member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting a Kentucky Spirit Member Services Representative. At the pharmacy the member will need to provide the pharmacist with their prescription and their Kentucky Spirit ID card.