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Index of Subjects
EXCEPTIONS: Prescriptions exempt from prior authorization are noted in each Chapter relating to the specific therapeutic class of drugs or the specific requirement for prior authorization.
GRANDFATHER PROVISION: Provisions for grandfathering certain prescriptions in order to avoid any potential disruption in therapy are noted in each Chapter relating to the specific therapeutic class of drugs or the specific requirement for prior authorization.
If the PROMISe Point-Of-Sale On-Line Claims Adjudication System indicates that a prior authorization is required and the prescription or the refill has not been prior authorized, the pharmacist should notify the recipient and the prescriber that the prescription now requires prior authorization.
The clinical information provided during the course of the review must also be verifiable within the patient’s medical record. Upon retrospective review, the Department may seek restitution for the payment of the prescription and any applicable restitution penalties from the prescriber if the medical record does not support the medical necessity for the prescription. (See 55 Pa. Code § 1101.83(b)).
In evaluating a request for prior authorization of a prescription that requires prior authorization, the determination of whether the requested prescription is medically necessary will take into account the guidelines set forth in the chapter relating to the specific therapeutic class of drugs and/or the specific requirement for prior authorization.
When the PROMISe Point-Of-Sale On-Line Claims Adjudication System can verify that the recipient has a record that documents medical necessity for a prescription that requires prior authorization, the request will be automatically approved. Automated Prior Authorization Approvals are noted in each Chapter relating to the specific therapeutic class of drugs or the specific requirement for prior authorization.
Prior authorization personnel will review the request for prior authorization and apply the clinical guidelines to assess the medical necessity of the prescription. If the reviewer determines that the request for prior authorization of a prescription meets the medical necessity guidelines, the reviewer will prior authorize the prescription. The reviewer may request documentation from the medical record to assess medical necessity. (See 55 PA Code § 1101.51(d) and (e)). If the reviewer is unable to determine medical necessity, the prior authorization request will be referred to a physician reviewer for a medical necessity determination. The physician reviewer may request documentation from the medical record to determine medical necessity. (See 55 PA Code § 1101.51(d) and (e)). Such a request for prior authorization may be approved when, in the professional judgment of the physician reviewer, the services are medically necessary to meet the medical needs of the recipient.
The Department will consider requests to authorize multiple refills for a recipient when, in the professional judgment of the reviewer, treatment for the condition is expected to be ongoing. Multiple refills will not exceed six (6) months or five (5) refill supply, which ever comes first, from the time of the original filling of the prescription. (See 55 Pa Code § 1121.53(c)).
The Department will respond to requests for prior authorization within 24 hours of receiving all information reasonably necessary to make a decision of medical necessity.
The Department will notify the prescribing provider by return telephone call or fax indicating whether the requet for prior authorization is approved or denied. The Department will also send a written notice of approval or denial of a request for prior authorization to the prescribing provider and the recipient.
If the Department approves a request for prior authorization, a 10-digit prior authorization number will be issued. This number should be written on the prescription and in the medical record in the event that the prescriber needs to later refer to the number for the patient or pharmacy.
If the request to approve a prescription that requires prior authorization is denied or approved other than as requested, the recipient has the right to appeal the Department’s decision. The recipient has 30 days from the date of the prior authorization notice to submit the appeal in writing to the address listed on the notice. If the recipient has been receiving the drug that is being reduced, changed, or denied and an appeal is hand-delivered or postmarked within 10 days of the date of the notice, the Department will authorize the prescription for the drug until a decision is made on the appeal.