Clinical Services Team: Pharmacy Unit

What We Do

The DVHA Pharmacy Unit is responsible for managing all aspects of Vermont’s publicly funded pharmacy benefits programs. The pharmacy unit oversees the contract with DVHA’s pharmacy benefits manager (PBM) Change Healthcare. Together with its PBM, the Pharmacy Unit is responsible for: working with pharmacies, prescribers and members and resolving all drug-related issues; processing over 2 million pharmacy claims annually, facilitating appeals related to prescription drug coverage within the pharmacy benefit; making drug coverage determinations for pharmacy claims and physician-administered drugs; assisting with drug appeals and exception requests; overseeing federal, state, and supplemental drug rebate programs ; overseeing and managing the Drug Utilization Review Board; managing DVHA’s preferred drug list (PDL); and conducting pharmacy utilization management programs and drug utilization review activities focused on promoting rational prescribing practices and alignment with evidence-based clinical guidelines. The Pharmacy Unit enforces coverage rules in compliance with federal and state laws and implements legislative and operational changes to the pharmacy benefit programs as needed.  The Pharmacy unit also implements new programs and policies that support value-based payments and pharmacist clinical services. For example, the Unit implemented a payment structure for pharmacists performing Medication Therapy Management (MTM) activities, and also policies and procedures to support COVID testing by pharmacists during the Public Health Emergency.  

 

Please note that in the Summer of 2020, the Pharmacy Unit, the Clinical Operations Unit, and the Quality & Clinical Integrity Unit came together as the Clinical Services Team.  The Units are displayed separately in this scorecard due to their different lines of work.

Who We Serve

The Pharmacy Unit's primary stakeholders are Vermont Medicaid enrolled members, prescribers, and pharmacies. The unit also interacts with many other internal and external stakeholders such as other units within DVHA, other departments within the Agency of Human Services, various legislative committees, pharmaceutical manufacturers, and others.

How We Impact

The Pharmacy Unit established and actively manages a pharmacy best practice and cost control program designed to ensure that members receive high-quality, clinically appropriate, evidence-based medications in the most efficient and cost-effective manner possible.

Action Plan

The Pharmacy Unit's top priorities/initiatives in SFY20 are:

  • Coordinating management of drugs available through both medical benefit and pharmacy benefit
  • Developing new strategies for “extremely high cost” drugs (in excess of $500,000 per treatment)
  • Promoting value-based pharmacist clinical services to reduce adverse medication-related events and improve health outcomes.
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