Medicaid Formulary

​You may also want to visit:

Providers Home | Training | Fact Sheets | Links | Claims and Billing | New Provider | Webinars | ProviderOne Manuals | ProviderOne Security

Why is HCA implementing a formulary? What is the effective date?

The Washington State Legislature directed the Health Care Authority (HCA) to implement a formulary.

What is the Medicaid fee-for-Service formulary?

The Medicaid fee-for-Service formulary (the formulary) is a list of drugs covered for Medicaid clients. Drugs currently on the Preferred Drug List (PDL) will not be impacted as a result of the formularyHCA expects to apply the formulary to approximately twenty drug classes. Additional drug classes will be added to the formulary every 2 – 3 months thereafter until the agency has built a comprehensive formulary list.

Who decides what is on the formulary?

The State’s Drug Utilization Review (DUR) Board develops the formulary (see WAC 182-530-4000). The DUR Board is a team of physicians, pharmacists, nurses, and physicians’ assistants. They advise HCA in making decisions about medication coverage.

How does the DUR Board decide if a drug should be non-formulary?

The DUR Board reviews drugs approved by the Food and Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS) for treatment of specific conditions. They consider evidence of safety, effectiveness, and clinical outcomes. The Board decides what medications work best for Medicaid clients and keeps them on the formulary. They remove drugs they find do not work as well as others. If some medications work the same for most people, the Board keeps the most cost effective drugs on the formulary and removes drugs that provide the least value.

How does this impact my practice?

Like any drugs covered by Medicaid, drugs on the formulary may require authorization. Medicaid will only cover the drugs when they are medically necessary.

Drugs that are non-formulary will be non-covered. In order to request a non-formulary medication for your client, you will need to request a non-formulary justification (NFJ) through the agency (WAC 182-530-2600). A non-formulary justification (NFJ) is a written request explaining why the formulary medications available are not a good choice for your client. In addition, the justification should explain why your client’s condition is different from other clients with the same diagnosis.

Additional details will be posted online outlining the process as well as which forms to use to request.

Please note: It is important to note that the formulary does not apply to drugs that are paid for by a Medicaid managed care plan. The formulary, however, does apply to prescriptions for managed care clients when Medicaid pays for the medication instead of the client’s health plan.

How will I know if my client has a prescription for a non-formulary drug?

HCA will provide prescribers with information for clients who have a prescription for a non-formulary drug. In addition, HCA will be notifying clients if they currently take a medication that is non-formulary. HCA will also notify pharmacies.

HCA will publish a list of drugs that the DUR Board decided to remove from the formulary. The formulary decisions will be posted online.

If you are prescribing a medication not on the formulary, we encourage you select and prescribe a new medication to treat the client’s condition. You can elect to see the client or contact the client with a new prescription based on your medical judgment.

How does this impact new prescriptions and refills?

New prescriptions for non-formulary medications will be non-covered services for Medicaid clients, unless you choose to submit a Non-Formulary Justification which HCA approves. Most prescription refills will be impacted in the same way. For some drugs and drug classes the DUR Board may designate that clients should be allowed to remain on non-formulary medications they are stable on. If the DUR Board designates a drug or class to be subject to continuation of therapy, refills for those products will not be affected.

Can your client pay cash for a non-formulary drug?

Yes. If you, the prescriber, and the client decide to prescribe a non-formulary medication and you do not submit an NFJ, or HCA denies the NFJ, the client can pay cash for the medication. The client will need to fill out paperwork at their pharmacy verifying that they voluntarily chose to pay for the medication.