Brand Requested Block at Point-Of-Sale

Standard Operating Procedure

Policy

The WTCHP has a mandatory generic policy. Assuming availability of a generic version of the drug on the market, generic is required except when the prescriber indicates the brand name is mandatory [“Dispense as Written” (DAW) =”1”]. Brand prescriptions with DAW1 will be blocked at point of sale and referred to the CCE/NPN to review for clinical justification for use of the brand form. The program does not authorize brand prescriptions based only on Member request.Brand preparations of thyroid replacement therapy (e.g. Synthroid) and warfarin products (e.g. Coumadin) are exceptions to this rule. The mandatory generic policy applies to over-the-counter medications that the program authorizes as WTCHP-related.

Procedures

Brand Requested Block at Point-of-Sale

1. Pharmacies will fill prescriptions for brand name medications with generic, if generic is available, unless the prescriber has indicated “Dispense as Written”.
2. If a member attempts to fill a prescription for a medication for a brand name drug with prescriber indication “Dispense as Written”, this will be blocked at the Point-of-Sale and the CCE/NPN will be notified of this block, which will be placed on the work queue of the CCE/NPN individual with override authority.
3. The CCE/NPN individual with approval authority should check the Member profile in VitalPoint to review the past prescription, authorization and block history; review the Member clinical recordsand then determine whether there is justification for the request for the brand formulation.
4. If the clinical documentation supports the need for the brand formulation, authorize for the appropriate period of time, up to one year, select “Brand medication allowed” and provide details about the rationale for authorizing the brand name drug in the VitalPoint comments section and in the Member clinical record.
5. If the situation does not support the need for the brand formulation, choose deny and explain in the comments section and Member clinical record. Brand block will be upheld, however CCE should note to dispense generic in comments section, if appropriate.
6. You may copy the documentation from VitalPoint justifying the decision to include in the Member’s clinical documentation or other auditing documentation trail.

Over-the-Counter Medications

1. Because it is unusual for benefits programs to cover over-the-counter (OTC) medications, pharmacists may not know how to apply the mandatory generics rule to these medications. In order for the program to cover OTC medications as WTC-related, the CCE/NPN prescriber must write a prescription for this medication.
2. If the patient attempts to fill a brand name OTC medication, the system will block this fill and the PBM will reach out to the pharmacy for generic substitution.
3. Using the generic name of the OTC medication when writing the prescription will help prevent such blocks.
4. If unsure whether the name represents a brand name, note on the prescription “dispense generic”to alert the pharmacist to the program rules and prevent blocks for unintended brand name OTC fills.
5. If the prescriber wants the brand name OTC, then the above instructions and procedures for prescription drugs apply, including need to indicate “Dispense as Written”, and the subsequent blocking, review, decision and documentation.

Quality Controls:

The PBM monitor VitalPoint overrides for brand therapy drugs to permit auditing and for identification of any trends that warrant attention of the P&T Committee.

The CCE/NPN should ensure that the comments in VitalPoint and the Member medical records provide clear documentation about the need for brand medication rather than generic.