Grandfathering Definition and Criteria
Approved August 24, 2004
Grandfathering definition
Allowing an individual who has been stabilized on a medication to continue taking it without having to meet any authorization criteria.
Grandfathering criteria
- If the DFC determines the drugs within a class to be clinically equivalent, then the drugs should be interchangeable for the majority of the patients. It is patient-specific criteria that would make changing between drugs inadvisable.
- There are patient-specific parameters that may require approval of the nonpreferred or restricted drugs for a patient who does not meet the PA criteria determined by the DFC (i.e., grandfathering). For example:
- Patient has mental disability that would make drug switching medically inadvisable and would adversely impact patient care
- Patient has a care-giver or living arrangement that would make using the preferred drugs very difficult and that would impact patient care
- Patient has language barriers that would make using the preferred drug difficult due to re-training, patient/family education, or put the patient at risk for medication errors such as missed therapy, duplicate therapy, or other dosage or administration errors
- One month may be approved if there is concern on the part of the pharmacist that the patient will have interruption in therapy due to the operational aspects of switching drugs
- There may be disease-specific parameters that require approval of nonpreferred or restricted drugs without meeting the set PA criteria
- For example, patient has a history of having a brittle, difficult to stabilize disease state
- Patient has a condition, such as accelerated liver metabolism, liver failure or renal failure, where using the preferred drugs is not advisable
- An antipsychotic or other mood stabilizing drug will be grandfathered if it was started during an episode of acute care, such as a hospitalization or other place of care that offers acute services
Questions?
DHS Help Desk 651-431-2700 (1-800-366-5411)
