- Medicaid To Requir Prior Authorization Of Ten Mental Health Drugs
-
Effective June 15, 2009 the Iowa Medicaid Enterprise will require prior authorization for the following ten mental health medications: Abilify Discmelt, Invega, Pristiq, Risperdal M-Tab, Zyprexa Zydis, Luvox and Seroquel XR.
-
-
Grandfathering: Non-preferred drugs will require prior authorization for new users only. The change in drug status to non-preferred will only stop pharmacy claims from paying for "new users" or those members that have not had the drug previously paid by Medicaid. If the member does not have a history of the requested drug in the Medicaid paid claims system, a prior authorization will be required. Established users will be grandfathered by the point of sale (POS) system. The POS system will look back 180 days for paid claims for the specific drug and allow members to continue to get the same drug without restrictions. All strengths of the grandfathered drug will be included in the grandfathering. This grandfathering process will remain in place for the duration of the member's eligibility.
-
Prior Authorization Process: Prior Authorization (PA) Forms are located at www.iowamedicaidpdl.com. A decision will be made within 24 hours of the request. The average time is 2-3 hours and the prescriber will be notified by fax of decision with dates of authorization if approved. .
-
-
Denied Authorizations: If the initial request is denied, the pharmacist and physician will be faxed and the patient sent a letter. The pharmacist may use up to a 72-hour override one time if PA can not be immediately received. The physician can call the Provider Help Desk to speak to the pharmacist that reviewed the request.
-
-
A physician can fax a second request giving additional clarifying medical information. If the second request is denied, it can be referred to the IME Meduical Director for further review and discussion. If deemed necessary by the Medical Director, it will be refered to a consulting board certified psychiatrist.
-
Formal Appeal: A formal appeal must be made within 30 days. The Department of Human Services determines if the appeal is eligible for a hearing. If approved, it will then be heard by an administrative law judge and the decision is issued typically in less than 90 days.
-
-
-
-
Criteria for Prior Authorizations:
- Abilify Discmelt, Invega, Pristiq, Risperdal M-Tab, and Zyprexa Zydis will become nonpreferred and require prior authorization through the Modified Formulations PA as follows: Payment for a non-preferred isomer, pro-drug, metabolite, and/or alternative delivery system will only be considered for cases in which there is documentation of a recent trial and therapy failure with the original parent drug of the same chemical entity, unless evidence is provided that use of the original product would be medically contraindicated.
- Luvox CR and Seroquel XR will become nonpreferred and continue to require prior authorization through the Extended Release PA as follows: Payment for the extended release formulation will be considered only for cases in which there is documentation of previous trial and therapy failure with the immediate release product of the same chemical entity, unless evidence is provided that use of the immediate release product would be medically contraindicated.
- Pexeva will become nonpreferred. Current prior authorization criteria for non-preferred drugs is: Payment for a non-preferred medication will be authorized only for cases in which there is documentation of previous trial and therapy failure with the preferred agent, unless evidence is provided that use of these agents would be medically contraindicated.)
- Metadate CD and Ritalin LA will become nonpreferred and will continue to require prior authorization through the ADD/ADHD/Narcolepsy agents PA as follows: Prior authorization is required for ADD/ADHD/Narcolepsy agents for members 21 years of age or older. The category includes amphetamine salt combos, atomoxetine, dexmethylphenidate HCl, dextroamphetamine, lisdexamfetamine, methamphetamine HCl, methylphenidate HCl, and modafinil. Prior approval shall be granted if there is documentation of one of the following: Attention deficit disorder, Attention deficit hyperactivity disorder, Narcolepsy and Other FDA approved indications.
|