Common use of Prior Authorization for Prescription Drugs Clause in Contracts

Prior Authorization for Prescription Drugs. The MCO must adopt prior authorization policies and procedures that comply with state and federal laws, including 42 U.S.C. §1369r-8 and Texas Government Code §531.073 and §533.005. The MCO must adhere to HHSC’s PDL for Medicaid. Preferred drugs must adjudicate as payable without prior authorization, unless they are subject to Clinical Edits. HHSC approval is required for all Clinical Edit policies and any revisions thereto. HHSC’s Medicaid and CHIP prior authorization policies, and the Medicaid PDL, are available on HHSC’s website at xxxx://xxx.xxxxxxxxxxxx.xxx/xxxxx.xxxxx. HHSC will provide the MCO written notice of changes to website information, and will identify Clinical Edits that are mandatory for MCOs on its Vendor Drug Program website. HHSC’s website includes exception criteria for each drug class included on HHSC’s Medicaid PDL. These exception criteria describe the circumstances under which a non-preferred drug may be dispensed without a prior authorization. The MCO may require that the prescriber’s office request prior authorization as a condition of coverage or payment for a prescription drug provided that: 1) a decision whether to approve or deny the prescription is made within 24 hours of the prior authorization request, and 2) if a Member’s prescription for a medication is not filled when a prescription is presented to the pharmacist due to a prior authorization requirement, the MCO must instruct the pharmacist to dispense a 72 hour emergency supply of the prescribed medication if the provider cannot be reached. The pharmacy may fill consecutive 72 hour supplies if the prescriber remains unavailable. The MCO must reimburse the pharmacy for dispensing the temporary supply of medication. The MCO may not charge pharmacies for prior authorization transaction costs or for any software costs related to processing prior authorizations. The MCO must provide access to a toll-free call center for prescribers to call to request a prior authorization for non-preferred drugs or drug that are subject to Clinical Edits. The MCO must allow prescribers to submit automated prior authorization requests, as well as requests by phone or fax. If the MCO or its PBM operates a separate call center for prior authorization requests, the prior authorization call center must meet the provider hotline performance standards set forth in Section 8.1.4.7, “Provider Hotline.” The MCO may not require a prior authorization for any drug exempted from prior authorization requirements by federal law. For drug products purchased by a pharmacy through the Health Resources Services Administration (HRSA) 340B discount drug program, the MCO may only impose Clinical Edit prior authorization requirements. These drugs must be exempted from all PDL prior authorization requirements. The MCO must notify the prescriber’s office of a prior authorization approval or denial within 24 hours of the prior authorization request. In the event that the MCO cannot make a prior authorization determination within 24 hours, the MCO 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. The requirement that the Member be given at least a 72-hour supply for a new medication does not apply when the dispensing pharmacist determines that the taking of the prescribed medication would jeopardize the health or safety of the Member. In such event, the MCO must require that its participating pharmacist make good faith efforts to contact the prescriber. A provider may appeal prior authorization denials on a Member’s behalf, in accordance with Sections 8.2.6 (Medicaid) and 8.4.2 (CHIP).

Prior Authorization for Prescription Drugs. The MCO must adopt prior authorization policies and procedures for non-preferred drugs (i.e., drugs that comply are not on HHSC’s PDL) that complies with state and federal laws, including 42 U.S.C. §1369r-8 and Texas Government Code §531.073 and §533.0051369r. The MCO must adhere to HHSC’s PDL for Medicaid. Preferred drugs must adjudicate as payable without prior authorization, unless they are subject to Clinical Edits. HHSC approval is required for all Clinical Edit policies. The MCO must adopt HHSC’s prior authorization policies and any revisions theretounless HHSC grants a written exception. HHSC’s Medicaid and CHIP prior authorization policies, and the Medicaid PDL, are available on HHSC’s website at xxxx://xxx.xxxxxxxxxxxx.xxx/xxxxx.xxxxx. HHSC will provide the MCO written notice of changes to website information, and will identify Clinical Edits that are mandatory for MCOs on its Vendor Drug Program website. HHSC’s website includes exception criteria for each drug class included on HHSC’s Medicaid PDL. These exception criteria describe the circumstances under which a non-preferred drug may be dispensed without a prior authorization. The MCO may require that the prescriber’s office request prior authorization as a condition of coverage or payment for a prescription drug provided that: 1) a decision whether to approve or deny the prescription is made within 24 hours of the prior authorization request, and 2) if a Member’s prescription for a medication is not filled when a prescription is presented to the pharmacist due to a prior authorization requirement, the MCO must instruct the pharmacist to dispense a 72 hour emergency supply of the prescribed medication if the provider cannot be reached. The pharmacy may fill consecutive 72 hour supplies if the prescriber remains unavailable. The MCO must reimburse the pharmacy for dispensing the temporary supply of medication. The MCO may not charge pharmacies for prior authorization transaction costs or for any software costs related to processing prior authorizations. The MCO must provide access to a toll-free call center for prescribers to call to request a prior authorization for non-preferred drugs or drug that are subject to Clinical Edits. The MCO must allow prescribers to submit automated prior authorization requests, as well as requests by phone or fax. If the MCO or its PBM operates a separate call center for prior authorization requests, the prior authorization call center must meet the provider hotline performance standards set forth in Section 8.1.4.7, “Provider Hotline.” The MCO may not require a prior authorization for any drug exempted from prior authorization requirements by federal law. For drug products purchased by a pharmacy through the Health Resources Services Administration (HRSA) 340B discount drug program, the MCO may only impose Clinical Edit prior authorization requirements. These drugs must be exempted from all PDL prior authorization requirements. The MCO must notify the prescriber’s office of a prior authorization approval or denial within 24 hours of the prior authorization request. In the event that the MCO cannot make a prior authorization determination within 24 hours, the MCO 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. The requirement that the Member be given at least a 72-hour supply for a new medication does not apply when the dispensing pharmacist determines that the taking of the prescribed medication would jeopardize the health or safety of the Member. In such event, the MCO must require that its participating pharmacist make good faith efforts to contact the prescriber. A provider may appeal prior authorization denials on a Member’s behalf, in accordance with Sections 8.2.6 (Medicaid) and 8.4.2 (CHIP).