Common use of Pharmacy Prior Authorizations Clause in Contracts

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. A. The Contractor shall: shall conduct a Prior Authorization (1PA) Develop clinical PA review criteria; (2program that complies with the requirements of section 1927(d)(5) Ensure all review criteria are easily understood of the Social Security Act and widely available with Department requirements, as if such requirements apply to Providers through various media; (3) Develop a plan for administering the Contractor instead of the Department. The Contractor’s PA program that doesn’t unduly disrupt 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: (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 A. Clinical PA review criteria shall be aligned with FDA approved indications, best clinical practice standards, and/or other national standards;. (6) The Contractor’s Grievance and Appeal procedure required by this Contract B. A physician peer review shall be available upon a Provider’s request for prescribing any denial made at a pharmacist review level. C. PA determinations including those from escalated reviews shall be made 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 provider within twenty-twenty- four (24) hours from the initial request;request including weekends in compliance with the provisions of OBRA 1990 mandate, Section 1927 of the Social Security Act, and other federal regulations. (7) Document all D. 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. 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. E. In the event the a prescription is for a non-preferred drug awaiting PA and the pharmacist pharmacy cannot reach the prescribing physician or physician, and when the Contractor or its agent for approval and the dispensing pharmacist using reasonable clinical judgment deems it necessarynecessary 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 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 it this quantity 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