Pharmacy Prior Authorizations. The Contractor shall conduct a Prior Authorization (PA) program that complies with the requirements of section 1927(d)(5) of the Social Security Act and with Department requirements, as if such requirements apply to the Contractor instead of the Department. The Contractor’s PA program shall ensure there is no undue disruption of a Member’s access to care; shall prevent penalization of the Provider or Member, financially or otherwise, for such PA requests or approvals; and shall incorporate the minimum requirements described herein: A. Clinical PA review criteria shall be aligned with FDA approved indications, best clinical practice standards, and/or other national standards. B. A physician peer review shall be available upon a Provider’s request for any denial made at a pharmacist review level. C. PA determinations including those from escalated reviews shall be made and communicated to the requesting provider within twenty- four (24) hours from the initial request including weekends in compliance with the provisions of OBRA 1990 mandate, Section 1927 of the Social Security Act, and other federal regulations. D. All PA activities and decisions shall be documented in Contractor’s online pharmacy case management system. This information shall be available for immediate review at the Department’s request or other timeframe as specified by the Department. E. In the event a prescription is for a drug awaiting PA and the pharmacy cannot reach the prescribing physician, and when the dispensing pharmacist using reasonable clinical judgment deems it necessary to avoid imminent harm or injury to the Member, a seventy-two (72) hour emergency supply shall be provided. If the physician prescribed an amount of 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 Contractor shall pay for this quantity even if it exceeds a calculated seventy-two (72) hour supply. Contractor shall instruct the pharmacy providers how to perform the override in the NCPDP environment of the POS pharmacy claims processing system. F. Contractor’s PA process shall include procedures for Member appeals and grievances submitted by the Member or the prescriber authorized to act on behalf of the Member related to PAs denied after the final escalated review. Contractor’s procedures for PA related appeals and grievances shall be in accordance with Section 25.2 Member Grievance and Appeal Policies and Procedures and Section
Appears in 2 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract
Pharmacy Prior Authorizations. A. The Contractor shall conduct 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 Prior Authorization (PA) plan for administering the PA program that complies with the requirements of section 1927(d)(5) of the Social Security Act and with Department requirements, as if such requirements apply to the Contractor instead of the Department. The Contractor’s PA program shall ensure there is no undue disruption of 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 prevent penalization of the Provider or Member, financially or otherwise, be available for prescribing and pharmacy Providers that wish to challenge a drug PA denial. The Grievance and Appeal procedure for such PA requests or approvals; and denials shall incorporate the minimum requirements described herein:
A. Clinical PA review criteria shall be aligned with FDA approved indications, best clinical practice standards, and/or other national standards.
B. A physician peer review shall be available upon a Provider’s request for any denial made at a pharmacist review level.
C. PA determinations including those from escalated reviews shall be made and ensure decisions are communicated to the requesting provider Provider within twenty- twenty-four (24) hours from the initial request including weekends in compliance with the provisions of OBRA 1990 mandate, Section 1927 of the Social Security Act, and other federal regulations.request;
D. All (7) Document all PA activities and decisions shall be documented 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 as specified by the Department.
E. 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 a the prescription is for a non-preferred drug awaiting PA and the pharmacy pharmacist cannot reach the prescribing physician, physician or the Contractor or its agent for approval and when the dispensing pharmacist using reasonable clinical judgment deems it necessary to avoid imminent harm or injury to the Membernecessary, 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- 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 this quantity it even if it exceeds a calculated seventy-two (72) hour supply. The Contractor shall instruct the pharmacy providers Providers how to perform the override in the NCPDP environment of the POS pharmacy claims processing system.
F. Contractor’s PA process shall include procedures for Member appeals and grievances submitted by the Member or the prescriber authorized to act on behalf of the Member related to PAs denied after the final escalated review. Contractor’s procedures for PA related appeals and grievances shall be in accordance with Section 25.2 Member Grievance and Appeal Policies and Procedures and Section
Appears in 2 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract
