D-2.2. Population Impact

HHSC pharmacists will estimate the potential use of the drug by people enrolled in Medicaid by reviewing the following:

• NDC package inserts and indications
• Compendia and epidemiology clinical studies
• Texas Medicaid claim and encounter utilization (in situations when a manufacturer replaces one NDC with another)
• CMS website (medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/) to identify if other states have reported drug utilization data for the NDC). The data includes state, drug name, NDC, number of prescriptions, and dollars reimbursed if available.
• Other sources, such as specialty pharmacies, manufacturers, and various foundations

The pharmacist will determine if the drug requires clinical prior authorization and, if needed, develops the criteria.  Using clinical judgment and the information gathered above, the pharmacist will then estimate the number of people enrolled in fee-for-service and managed care who meet the coverage requirements.