The Medicare drug approval process

Priority Health develops the Medicare Approved Drug List (formulary) through a rigorous process to ensure that your prescription drug coverage is safe and effective.

P&T Committee: drug reviews and approvals

The Pharmacy & Therapeutic Committee (P&T Committee) meets 6 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 actively practicing physicians and pharmacists and representatives from the Priority Health Pharmacy and Medical departments.

Approving drugs

The P&T Committee uses specific, medically accepted guidelines to determine whether a drug should be added to the Medicare formulary or approved for a 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)

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.