Pharmacy Prior Authorizations. The Contractor must establish policies and procedures to comply with the Division’s Prior Authorization criteria in accordance with the PDL guidance for the drugs listed on the PDL. The Contractor may not promote adherence to a PDL or preferred drug program other than that which has been approved by the Division. The Contractor may approve drugs outside of the PDL when one of the following Prior Authorization criteria is satisfied:
a. Member must have used the preferred agents for at least a thirty (30) calendar day course of treatment per drug and failed trials within six (6) months prior to requesting the Prior Authorization and there is documentation of therapeutic failure of preferred drugs; or
b. Adverse event(s) reaction(s) to preferred medications; or
c. Contraindications to preferred medications (i.e. drug interaction, existing medical condition preventing the use of preferred medications). The Contractor must establish criteria and coverage policies for drugs not listed on the PDL, which must be approved by the Division. The Contractor must ensure that decisions regarding policies and procedures for prescription drugs are made in a clinically sound manner. The Division’s Office of Pharmacy’s approval is required for all Clinical Edit policies. The Division must receive this criteria and coverage policies for advanced written approval forty-five (45) calendar days prior to implementation.
Pharmacy Prior Authorizations. A. The Contractor shall:
(1) Develop clinical PA review criteria;
(2) Ensure all review criteria are easily understood and widely available to Providers through various media;
(3) Develop a plan for administering the PA program that doesn’t unduly disrupt a Member’s access to care;
(4) Ensure that all PAs conducted via telephone meet the service and quality standards required by this Contract;
(5) Ensure that PAs are based on national standards;
(6) The Contractor’s Grievance and Appeal procedure required by this Contract shall be available for prescribing and pharmacy Providers that wish to challenge a drug PA denial. The Grievance and Appeal procedure for such PA denials shall ensure decisions are communicated to the requesting Provider within twenty-four (24) hours from the initial request;
(7) Document all PA activities and decisions in the Contractor’s online pharmacy case management system. This information shall be available for immediate review at the Department’s request or other timeframe specified by the Department.
B. A Member is entitled to drug(s) prescribed by a prescribing Provider when any of the following criteria are met:
(1) Prescribed drug(s) are on the PDL, subject to obtaining a PA if required.
(2) PA is obtained if needed prior to the dispensing of the drug(s).
(3) Therapeutic substitution is made when authorized by the prescribing Provider, subject to obtaining a PA if required. In the event the prescription is for a non-preferred drug and the pharmacist cannot reach the prescribing physician or the Contractor or its agent for approval and the pharmacist deems it necessary, a seventy-two (72) hour emergency supply shall be provided. If the physician prescribed an amount of the drug that is less than a seventy-two (72) hour supply but is packaged so that it must be dispensed intact, the pharmacist may dispense the packaged drug and the Contractor shall pay for it even if it exceeds a seventy-two (72) hour supply. The Contractor shall instruct pharmacy Providers how to perform the override in the NCPDP environment of the POS pharmacy claims processing system.
Pharmacy Prior Authorizations. The Contractor agrees that during the first 90 days of an enrollment that the Department’s Fee- For-Service prior authorization for pharmacy services or a prior authorization which has been issued by another Health Plan to an Enrollee in the Contractor’s Health Plan for pharmacy services will be honored for at least one temporary 30 day fill unless the prescription is written for less than 30 days by the prescriber.
