Prior Authorization for Outpatient Prescription Drugs Sample Clauses

Prior Authorization for Outpatient Prescription Drugs. The PH-MCO may require Prior Authorization as a condition of coverage or payment for an outpatient prescription drug provided that 1) the PH-MCO provides a response to the request for prior authorization by telephone or other telecommunication device indicating approval or denial of the prescription within twenty-four

Prior Authorization for Outpatient Prescription Drugs. The Contractor may require prior authorization as a condition of coverage or payment for an outpatient prescription drug provided that 1) a decision whether to approve or deny the prescription is made within twenty-four (24) hours, and 2) if a Member's prescription for a medication is not filled when a prescription is presented to the pharmacist, the PH-MCO must allow the pharmacist to dispense either a fifteen (15) day supply if the prescription qualifies as an Ongoing Medication, or a seventy-two (72) hour supply in other instances where this is an Immediate Need for the medication. The Contractor must issue a written denial notice, in the form attached as Exhibit N of this Agreement, Denial Notices, within twenty-four (24) hours from the time that the prescription is presented at the pharmacy. In the event that the Contractor cannot issue a written denial notice within twenty-four (24) hours, the Contractor must have procedures in place so as to permit the Member to receive a supply of the new medication such that the supply will not be exhausted prior to receipt of the notice. For drugs not able to be divided and dispensed into individual doses, the Contractor will make provisions to allow the pharmacist to dispense the smallest amount that will provide at least a seventy-two (72) hour or fifteen (15) day supply, whichever is applicable. The Department will waive the seventy-two (72) hour supply requirement for medications and treatments under concurrent clinical review and treatments that are outside the parameter of use approved by the FDA or accepted standards of care. The Contractor must have procedures in place to assure that if a prescription for an Ongoing Medication is not authorized when presented at the pharmacy, the pharmacist shall dispense a fifteen (15) day supply of the prescription, unless the Contractor or its designated subcontractor issued a proper written notice of benefit reduction or termination at least ten (10) days prior to the end of the period for which the medication was previously authorized and a Grievance or DPW Fair Hearing request has not been filed. If the Member files a Grievance or DPW Fair Hearing request from a denial of an Ongoing Medication, the Contractor must authorize the medication until the Grievance or DPW Fair Hearing request is resolved. When medication is authorized due to the Contractor's obligation to continue services while a Member's Grievance or Fair Hearing is pending, and the final binding decisio...