Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-77.2 - Prior authorization

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definition.
The term prior authorization in pharmacy means an
				  approval for payment by the Oklahoma Health Care Authority (OHCA) to the
				  pharmacy before a prescription is dispensed by the pharmacy. An updated list of
				  all products requiring prior authorization is available at the agency's
				  website.
(b)
Process.
Because of the required interaction between a prescribing provider (such as a
				  physician) and a pharmacist to receive a prior authorization, OHCA allows a
				  pharmacist up to thirty (30) calendar days from the point of sale notification
				  to provide the data necessary for OHCA to make a decision regarding prior
				  authorization. Should a pharmacist fill a prescription prior to the actual
				  authorization he/she takes a business risk that payment for filling the
				  prescription will be denied. In the case that information regarding the prior
				  authorization is not provided within the thirty (30) days, claims will be
				  denied.
(c)
Documentation.
Prior authorization petitions with clinical
				  exceptions must be mailed or faxed to the Medication Authorization Unit of
				  OHCA's contracted prior authorization processor. Other authorization petitions,
				  claims processing questions and questions pertaining to Drug Utilization Review
				  (DUR) alerts must be addressed by contacting the pharmacy help desk.
				  Authorization petitions with complete information are reviewed and a response
				  returned to the dispensing pharmacy within twenty-four (24) hours. Petitions
				  and other claim forms are available on the OHCA public website.
(d)
Emergencies.
In an emergency
				  situation, the OHCA will authorize a seventy-two (72) hour supply of
				  medications to a member. The authorization for a seventy-two (72) hour
				  emergency supply of medications does not count against the SoonerCare limit
				  described in OAC
				  317:30-5-72(a)(1).
(e)
Utilization and
				  scope.
There are three (3) reasons for the use of prior authorization:
				  utilization controls, scope controls and product based controls. Product-based
				  prior authorizations, including step therapy protocols as defined by Section
				  7310(A)(4) of
				  Title 63 of the Oklahoma Statutes, are covered in OAC
				  317:30-5-77.3.
				  The DUR Board recommends the approved clinical criteria and any restrictions or
				  limitations.
(1)
Utilization
				  controls.
Prior authorizations that fall under this category generally
				  apply to the quantity of medication or duration of therapy approved.
(2)
Scope controls.
Scope
				  controls are used to ensure a drug is used for an approved indication and is
				  clinically appropriate, medically necessary and cost effective.
(A) Medications which have been approved by
				  the Food and Drug Administration (FDA) for multiple indications may be subject
				  to a scope-based prior authorization when at least one(1) of the approved
				  indications places that drug into a therapeutic category or treatment class for
				  which a prior authorization is required. Prior authorizations for these drugs
				  may be structured as step therapy or a tiered approach as recommended by the
				  DUR Board and approved by the OHCA.
(B) Prior authorization may be required to
				  assure compliance with FDA approved and/or medically accepted indications,
				  dosage, duration of therapy, quantity, or other appropriate use criteria
				  including pharmaco economic consideration.
(C) Prior authorization may be required for
				  certain non-standard dosage forms of medications when the drug is available in
				  standard dosage forms.
(D) Prior
				  authorization may be required for certain compounded prescriptions if the
				  allowable cost exceeds a predetermined limit as published on the agency's
				  website.