Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.28 - Prior Authorization

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 use and payment of drug items may be restricted and require prior
			 authorization. The Alabama Medicaid Agency will utilize the Pharmacy and
			 Therapeutics Committee to review and recommend drugs for prior
			 authorization.
(2) Drug class is
			 defined as a therapeutic group of pharmaceutical agents approved by the FDA as
			 defined by the American Hospital Formulary Service. Medicaid or the Pharmacy
			 and Therapeutics Committee may recommend a review to determine if prior
			 authorization is appropriate for a single drug or a drug class. The Pharmacy
			 and Therapeutics Committee will conduct such reviews, submit clinical data to
			 Medicaid and make a recommendation. The Medicaid Commissioner will make the
			 determination for placement on prior authorization.
(3) The requirement for prior authorization
			 of a drug will be based on a clinical review by the Pharmacy and Therapeutics
			 Committee of all relevant clinical and medical considerations including, but
			 not limited to, Medicaid Drug Utilization Review (DUR) data, Surveillance
			 Utilization Review (SUR) data, potential abuse, misuse, or inappropriate
			 prescribing and/or dispensing patterns by Alabama providers, inconsistency with
			 FDA approved labeling, inconsistency with uses recognized in the American
			 Hospital Formulary Service Drug Information, the authoritative source on sound
			 clinical evidence found in labeling, drug compendia, and peer reviewed clinical
			 literature on use of the drug.
(4)
			 Clinical bases for recommendations of the Pharmacy and Therapeutics Committee
			 will be in writing and available upon written request. Recommendations contrary
			 to prevailing clinical evidence will be justified in writing and available upon
			 written request. Medicaid will prepare a synopsis of the clinical reasoning
			 supporting recommendations which will be available upon written
			 request.
(5) Medicaid may require
			 prior authorization for generic drugs only in instances when the cost of the
			 generic product is significantly greater than the net cost of the brand product
			 in the same American Hospital Formulary Services (AHFS) therapeutic class or
			 when there is a clinical concern regarding safety, overuse or abuse of the
			 product. Medicaid must document the reason for prior authorization of any
			 generic product to include the cost effectiveness of such action or clinical
			 concern.
(6) Medicaid will develop
			 a set of medical criteria specifying the requirements for coverage
			 authorization. The criteria will be available to the public.
(7) Requests for prior authorization must be
			 initiated by the practitioner when deemed medically necessary.
(8) Prior authorizations will be reviewed by
			 Medicaid or its designated agent. When medical criteria as determined by
			 Medicaid are met, the prior authorization will be granted. If denied, adequate
			 medical justification may be submitted in writing by the prescribing physician
			 for reconsideration.
(9) Responses
			 to requests for prior authorization should be issued within eight (8) hours but
			 in no case more than twenty-four (24) hours after receipt of the request. In
			 cases of emergency, provisions are made for dispensing a seventy-two (72) hour
			 supply of a covered outpatient prescription drug.
(10) Effective March 18, 2011, the Alabama
			 Medicaid Agency will implement a Gold Standard Program, an incentive program
			 for high PDL complaint prescribing providers that will reward a limited group
			 of providers with prior authorization (PA) exemption of drugs when certain
			 prescription-based criteria are met in a given timeframe on regular basis.
			 Certain exclusions will apply. Alabama Medicaid will determine which providers
			 meet and maintain the Gold Standard program criteria on a regular
			 basis.
Author:
Tiffany Minnifield, Associate Director,
				  Pharmacy Administrative Services
Statutory Authority:
State Plan Attachment 3.1-A
				  and 4.18-B; Title XIX, Social Security Act; 42 CFR Section 447.331 &
				  Section 401, et seq.; Omnibus Budget Reconciliation Act of 1990 (Public
				  Law 101-508).