Chapter 3 – Health Care Operations

3.5.5 Electronic Health Record System Medication Catalog and CCHCS Drug Formulary

• Policy

  • California Correctional Health Care Services (CCHCS) Pharmacy Services in collaboration with the Systemwide Pharmacy and Therapeutics (P&T) Committee shall maintain the Electronic Health Record System (EHRS) medication catalog.

  • The CCHCS Systemwide P&T Committee shall:

    • Maintain the CCHCS Drug Formulary (formulary) including adding and deleting medications.

    • Promote rational, safe, clinically appropriate, and cost-effective medication therapy within CCHCS.

    • Ensure optimal use of formulary medications to facilitate continuity of care.

    • Review nonformulary medication utilization and refer inappropriate use to institution and regional leadership.

• Procedure

  • General Requirements

    • The Statewide Chief of Pharmacy Services shall ensure that the current formulary is readily available in electronic format on the Pharmacy Lifeline page at CCHCS Drug Formulary.

    • Formulary medication usage is required.  Exceptions are outlined in Section (b)(3) below.

    • Pharmacy Services shall dispense:
      

    • The use of non-Food and Drug Administration (FDA) approved products shall be limited to those with substantial medical peer-reviewed literature supporting their use. Any requests to add such products to the medication catalog must include this information.

    • Providers requesting a brand name medication when a generic medication is available shall include strong clinical justification as to why a generic or an alternative generic medication is inappropriate.

  • Changes to the EHRS Medication Catalog

    • Requests for Additions

      • Medications added to the catalog shall be nonformulary unless a decision has been made at the Systemwide P&T Committee to change the medication to formulary.

      • Considerations prior to addition of a National Drug Code (NDC) to the catalog may include, but are not limited to:

        • Availability of peer-reviewed literature supportive of efficacy and safety.

        • Determination of whether medications need to be added to the Heat Alert, High Alert, and National Institute for Occupational Safety and Health hazardous medication lists.

        • Review of FDA Risk Evaluation and Mitigation Strategy requirements.

        • Recommendations from the Drug Utilization Review Subcommittee.

        • Availability of NDCs currently in the EHRS.

    • Requests for Deletions

      • Medications requiring removal from the catalog shall be reviewed for active orders prior to deletion.

  • Justification for Nonformulary Medication

    • Justification for prescribing a nonformulary medication:

      • Shall be included as part of the Computerized Provider Order Entry (CPOE) process.  If the CPOE is unavailable, the provider shall provide both the CDC 7221, Physician’s Orders, and CDCR 7374, Nonformulary Drug Request, to the pharmacy.

      • May include, but is not limited to:

        • New arrivals to a Reception Center from a non-California Department of Corrections and Rehabilitation (CDCR) facility.

        • Documentation of treatment failures with medications listed in the formulary.

        • Documentation of allergy, side effect, or adverse reaction that prevents the use of a formulary medication.

        • Medications recommended by a specialist when formulary options or more cost-effective alternatives are not available.

        • Medications having the potential to prevent mortality and morbidity when formulary options are not available.  The requesting provider may be asked to supply supporting scientific literature.

  • Formulary Change Requests

    • The Systemwide P&T Committee has exclusive authority to add or delete:

      • Medications from the formulary.

      • Use criteria or restrictions from formulary medications.

    • Requests to add, delete, or change restrictions for formulary medications must follow the following process:

      • The provider shall submit a CDCR 7373, Formulary Change Request, and supporting scientific literature to the appropriate discipline as follows:

        • For medical indications, to the institution Chief Medical Executive (CME) and Regional Deputy Medical Executive (DME).

        • For dental indications, to the Regional Dental Director or designee.

        • For mental health indications, to the Chief Psychiatrist or designee. For institutions without psychiatry leadership, requests shall be submitted to Assistant Deputy Director of Complex and Psychiatric Services or designee.

      • If the above leadership determines that the request should be considered further, the request and supporting documentation shall be forwarded to the Systemwide P&T Committee.

    • Denied formulary addition requests may be reconsidered again 12 months after the initial review or if new practice standards are published indicating a different role for the medication.

    • Pharmacy Services, by delegated authority from the Systemwide P&T Committee, may make non-clinically significant changes to the CCHCS Drug Formulary.

  • Monitoring of Nonformulary Use

    • To ensure that resources are used efficiently, effectively, and safely, nonformulary utilization shall be reviewed:

      • On a monthly basis by the institution Medication Management Subcommittee.

      • On a quarterly basis by the Systemwide P&T Committee.

    • On an annual basis, the Systemwide P&T Committee shall review nonformulary use criteria to ensure criteria are up to date and consistent with current practice.

    • For issues related to the misuse or abuse of nonformulary medications, depending on the breadth of the noncompliance, the Systemwide P&T Committee may:

      • Refer concerns to the institution Medication Management Subcommittee.

      • Refer providers to the institution CME, Regional DME, institution Chief Psychiatrist or designee, Regional Chief Psychiatrist, or Regional Dental Director for further review.

      • Require prior authorization as outlined in (b)(6) below.

    • At least every six months, Pharmacy Services at the headquarters level shall review procurement and utilization data and report any issues to the Systemwide P&T Committee including, but not limited to:

      • Pharmaceutical cost drivers.

      • Potential inappropriate utilization or overutilization concerns.

      • Nonformulary utilization.

  • Prior Authorization

    • Medications intended to follow the prior authorization process are those deemed by the Systemwide P&T Committee to be rarely appropriate or overused.

    • At least annually, the Systemwide P&T Committee shall review the list of medications that require prior authorization along with use criteria.

    • For medications requiring prior authorization, the provider shall submit the prior authorization request through the approved process.

    • Within three business days of receiving the prior authorization request, the institution CME, institution Chief Psychiatrist, or designated clinical team shall review the order for its appropriateness and respond with one of the following actions:

      • Authorize the request and have the provider enter the order for the pharmacy to dispense it.

      • Recommend a formulary or nonformulary alternative.

      • Request further information.

    • For an urgent prior authorization request, the provider shall contact the institution CME or Chief Psychiatrist by phone to expedite the request.

    • Prior authorization is valid for up to one year from the approval date.  Renewed or transferred orders do not need to go through the prior authorization process during this period unless otherwise stated as part of its use criteria.

• References

• Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.11, CCHCS Systemwide Pharmacy and Therapeutics Committee

• Policy Control
  Executive Sponsor: Deputy Director, Medical Services
  Effective: 04/2007
  Revised: 11/12/2020, 11/23/2021, 10/05/2023, 07/01/2026