What are Formulary Medications?
Formulary drugs are reviewed and recommended by Gateway Health's P&T Committee. They are are chosen based on safety, efficacy, quality and cost. Doctors and pharmacists should use formulary drugs when appropriate.
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Compounded prescriptions are considered formulary drugs provided they contain at least one listed formulary drug in the final product. A claim for a compounded prescription should be submitted using either the NDC of the most expensive legend ingredient or may be submitted with all NDCs used in the compound. The software should be able to flag the prescription as a "Compounded Prescription". The compound ingredient cost must be manually entered by the pharmacy when submitting the most expensive legend ingredient. If the multi-ingredient compound logic is used the compound cost will be automatically calculated. Payment will only be made for FDA approved drugs and drugs not excluded from payment by Medical Assistance.
Generic substitution is required when an equivalent generic drug is available. Generic drugs are subject to specific reimbursement levels, such as Maximum Allowable Cost (MAC) price reimbursements. Drugs that are available in generic form will appear in bold. The bold font indicates that the generic drug product is on the formulary but the branded product is not. Requests for "Brand Necessary" medications will be considered a nonformulary medication request and will require authorization. The Gateway Health Request for Nonformualry Drug Coverage Form must be submitted with sufficient documentation to substantiate medical necessity of the brand name medication. Physicians are encouraged to prescribe generic medications whenever clinically appropriate.
For certain drugs, Gateway Health limits the amount of the drug that Gateway will cover. For example, Gateway provides coverage for 9 tablets of sumatriptan (generic Imitrex) 100mg every 30 days. Prescriptions in excess of the covered monthly quantity would require a medical exception request from the prescribing physician. Medications with quantity limits are denoted by QL in the online formulary. Quantity limits are based on the FDA recommended dosing.
Non-covered drugs include the following categories:
- Drugs and other items prescribed for obesity or appetite control
- Nonlegend drugs in the form of troches, lozenges, throat tablets, cough drops, chewing gum, mouthwashes and similar items
- Drugs and devices not approved by the FDA or whose use is not approved by the FDA
- Legend and nonlegend soaps, cleansing agents, dentifrices, mouthwashes, douche solutions, diluents, ear wax removal agents, deodorants, liniments, antiseptics, irrigants, emollients and other personal care items
- Legend and nonlegend food supplements and substitutes
- Durable Medical Equipment (DME) items
- Items prescribed or ordered by a physician who has been barred or suspended from participating in the Medical Assistance Program
- Fertility promoting agents
- Drugs for the treatment of erectile dysfunction
- Agents prescribed for cosmetic purposes or approved by the FDA for cosmetic purposes only
Gateway ONLY covers Food and Drug Administration (FDA) approved drugs.