HAR §17-1739.1-4.1. Prior authorization of drugs

(a) Selected drugs designated by the medical assistance program through the processes set forth in section 17-1737-71 pursuant to 42 U.S.C. 1396r(8)(d)(5) require prior medical authorization. (b) Preferred drug list: (1) The department may maintain a preferred drug list containing the names of drugs for which prior authorization will not be required under the medical assistance program. All other drugs not on the preferred drug list, but are in the same drug class as drug(s) placed on the preferred drug list, shall be placed on an enhanced prior authorization list. The department may seek the recommendations of an advisory committee to be comprised of licensed medical and pharmacy professionals regarding the products that may be placed on a preferred drug list. (2) The members of the advisory committee referred to in subsection (b)(1) shall be as determined by the department. The composition and number of members may change from time to time. (3) The advisory committee shall meet at times and locations as may be requested by the department. (4) The advisory committee’s recommendations may take into consideration all, or some, of the following: (A) Therapeutic value for the disease or condition under treatment; UNOFFICIAL 1739.1-10 (B) Clinical efficacy; (C) Safety; (D) Cost; and (E) Other considerations as determined by the committee. (5) The advisory committee’s recommendation(s) to the department shall be advisory only. The department may accept or reject all, or a portion, of the recommendation(s) of the advisory committee. (6) Pharmaceutical products which have been placed on a preferred drug list pursuant to the provisions of this subsection may also be temporarily deleted from the list by the department pending further review and recommendation of the advisory committee described in section 17-1737-71(b) or the decision of the department. The circumstances under which the department may temporarily delete a drug from the preferred drug list are for clinical and safety reasons and administrative cost. (7) Providers will be notified of changes made to the preferred drug list. (c) A request for outpatient drugs, including prescriptions for nursing facilities, that require prior authorization: (1) Shall be acted upon within twenty-four hours of receipt when the request is received within the business week; or (2) In an emergency situation, pharmacies can dispense a seventy-two hour supply of an outpatient drug which otherwise requires prior authorization under the following conditions: (A) The consequence of delaying the dispensing of the drug is a high probability of serious adverse effects on the person’s health. Serious adverse effects are hospitalization, medically necessary emergency room care, and loss of bodily function or life; (B) There is no similar medication available without prior authorization UNOFFICIAL 1739.1-11 or the patient has a documented intolerance for the similar agent; or (C) The patient’s physician documents that the patient is unable to use a generic form of a drug because of an allergy or history of a serious adverse reaction to the generic drug. (d) The department may require certain medications to be prior authorized or may place usage restrictions on certain drugs. (e) Services provided without the required prior authorizations are subject to denial of payment. (f) When a request for authorization is submitted for services which require prior authorization but have already been rendered, an explanation for the delay in submittal must be provided for consultant review. If the explanation adequately justifies the untimely submittal, the request shall be processed in accordance with the procedures stated in this section. If the explanation does not justify the untimely submittal, the request shall be denied. (g) An incomplete prior authorization form shall be returned to the sender. The form shall be deemed incomplete if the following is incomplete, illegible or missing. The following are examples and do not represent an exhaustive list: (1) The name and the identification number of the recipient; (2) The requesting physician’s signature, date, and provider number; (3) The supplier’s name, provider number, dates of service or period requested as determined by begin and end dates, and signature, if the service or item is not being provided by the requesting physician; (4) The diagnostic code or description; (5) The procedure code; and (6) For non-urgent requests, all attached copies of the form must be submitted together intact. When the newly completed form is received, the form shall be processed in accordance with the procedures stated in this section from the date the completed form is received. (h) When a request for authorization is deferred due to lack of supportive documentation to justify a service: UNOFFICIAL 1739.1-12 (1) The provider(s) shall be notified of the deferral. The notice shall include a reason for the deferral giving thirty calendar days from the date of the deferral notice to submit the requested information; and (2) If the requested information is not received within thirty calendar days from the date of the deferral notice, the request shall be denied; or (3) If all necessary information is received within thirty calendar days from the date of the deferral notice, the request for authorization shall be acted upon within twenty four hours by a DHS consultant or an authorized representative. If the request is denied, a notice to include a reason for the denial, shall be sent to the provider(s) and the recipient. (j) The department, through its medical consultants, may permit exceptions and determine level of care, medical appropriateness, and medical necessity. In disagreements between the provider and DHS’s authorized agent(s) regarding authorization of services and level of care determinations, the department’s medical consultant’s decision shall be final. Further appeal shall be pursued through the administrative appeals office or the courts. [Eff 03/11/04 ] (Imp: 42 C.F.R. §§456.1, 456.2, 456.3; 42 U.S.C. 1396r-8(d)(4) and (5))