How to Use the Formulary Review Suite

The Centers for Medicare & Medicaid Services (CMS) provides issuers and states with a number of review tools to check QHP Application data for errors that would result in corrections following submission. The Formulary Review Suite runs the non-discrimination formulary outlier review and the non-discrimination clinical appropriateness review. The formulary outlier review identifies and flags as outliers those plans that have unusually large numbers of drugs subject to prior authorization and/or step therapy requirements in 28 United States Pharmacopeia (USP) classes, compared to other plans in the state. The clinical appropriateness review analyzes the availability of covered drugs to ensure that issuers are offering a sufficient type and number of drugs in accordance with clinical guidelines for certain medical conditions, and checks to see whether certain drugs used in first-line treatment are available without prior authorization or step therapy. This video discusses the purpose of the tool, provides an overview of the tool’s layout, and walks viewers through running the tool using test data from the QHP Application templates. To learn more about the QHP certification process, visit www.qhpcertification.cms.gov.

Видео How to Use the Formulary Review Suite канала CMSHHSgov