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.
Appears in 4 contracts
Samples: Contract for Administration of the Children’s Health Insurance Program, Contract for Administration of the Children’s Health Insurance Program, Contract for Administration of the Children’s Health Insurance Program
