Prescription Drugs: Procedural Requirements

01. Request for PA. (7-1-26) a. PA is initiated by the prescriber by submitting the request to the Department in the prescribed IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 214 Page 64 format. (7-1-26) b. Whenever possible, the Department will use automated authorization, in which claims are adjudicated at point of sale using submitted National Council for Prescription Drug Programs (NCPDP) data elements or claims history to verify the Department's authorization requirements have been satisfied, without the need for the prescriber to submit additional clinical information. (7-1-26) 02. Response to Request. The Department will respond within twenty-four (24) hours to a request for PA of a covered outpatient prescription drug under 42 U.S.C. 1396r-8(d)(5)(A). (7-1-26) 03. Supplemental Rebates. (7-1-26) a. Supplemental rebates may be one (1) factor considered in determining a drug’s preferred drug status, but secondary to considerations of the safety, effectiveness, and clinical outcomes of the drug in comparison with other therapeutically interchangeable drugs. (7-1-26) b. The Department may negotiate with manufacturers supplemental rebates for prescription drugs that are in addition to those required by Title XIX of the SSA. There is no upper limit on the dollar amounts of the supplemental rebates the Department may negotiate. (7-1-26) 04. Dispensing Procedures. The following protocol is required for prescription filling: (7-1-26) a. Refills must be authorized by the prescriber on the original or new prescription order on file and each refill must be recorded on the prescription, logbook, computer print-out, or participant’s medication profile. Automatic refills are not allowed. All refills must be initiated by a request from the participant, prescriber, or another person, acting as an agent of the participant. Authorization for each refill must be received prior to the beginning of the filling process by the pharmacy. (7-1-26) b. Prescriptions must be maintained on file in pharmacies and available for immediate review by the Department upon written request. (7-1-26) 05. Return of Unused Prescription Drugs. Drugs dispensed in unit dose packaging must be returned to the dispensing pharmacy when the participant no longer uses the medication. The pharmacy that receives the returned drugs must credit the Department the amount billed for the cost of the drug less the professional dispensing fee. (7-1-26)