Only FDA-approved medications are eligible for coverage.
Investigational/Experimental Drug Use
Drugs prescribed for investigational or experimental purposes are not eligible for reimbursement.
Formulary drugs are those reviewed and recommended for inclusion by Gateway Health's P&T Committee. These drugs are selected based upon their safety, efficacy, quality and cost. Physicians and pharmacists should use formulary drugs when they believe it medically appropriate to do so.
A nonformulary drug is one that has not been recommended for inclusion by Gateway Health's P&T Committee on the basis of safety, efficacy, quality and cost. Physicians are requested to comply with the drug formulary when prescribing medications for participants when medically appropriate. A physician may request a nonformulary medication only if medical necessity or failure of formulary alternatives is documented, by the physician, on the Gateway Health Request for Nonformulary Drug Coverage Form. When presented a prescription for a nonformulary drug, a pharmacist should attempt to contact the prescribing physician in order to suggest formulary alternatives. If the physician is unavailable, the pharmacist should contact Gateway Health at 1-800-392-1147 to help secure a formulary alternative. After hours, weekends and holidays, the pharmacist must dispense a 96-hour emergency supply where there is an immediate need. An Immediate Need is defined in the HealthChoices Agreement as "A situation in which, in the professional judgment of the dispensing registered pharmacist and/or prescriber, the dispensing of the drug at the time when the prescription is presented is necessary to reduce or prevent the occurrence or persistence of a serious adverse health condition."
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.
Prior Authorization is necessary for coverage of certain medications. In these cases, clinical criteria, based on current medical information and approved by Gateway Health's P&T Committee and the Department of Public Welfare, must be met or additional information must be provided before coverage is approved. To avoid interruptions in therapy for ongoing medication, Gateway Health will provide a 15-day supply of the medication to the member. Prior authorizations are processed by calling Gateway Health at 1-800-392-1147. All requests for prior authorization will receive a response within 24 hours.
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 Food and Drug Administration (FDA) recommended dosing.
In some cases, Gateway Health requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Gateway may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Gateway will then cover Drug B.
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.
Over-the-Counter (OTC) Medications
Gateway Health does provide coverage for a number of OTC medications written as a prescription. Please refer to OTC Medication Coverage for a specific listing of covered products.
Gateway Health excludes all DESI (Drug Efficacy Study Implementation) drugs as defined by the FDA.
Gateway Health, by direction of DPW, excludes coverage for any drug marketed by a drug company who does not participate in the Medicaid Drug Rebate Program.
Medications Covered by Other Insurers (Coordination of Benefits and Third Party Liability)
As an agent of the Commonwealth of Pennsylvania Medical Assistance Program, Gateway Health is always the payor of last resort in the event that a member receives a medication that is covered by another payor source. The claim must be billed to the primary insurance, and subsequently billed online or submitted on a Universal Claim Form (UCF) to Gateway Health for any outstanding balance.
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