Medication Prior Authorization

Pharmacy Prior Authorization Process
HealthPAC POLICY AND PROCEDURE
Policy and Procedure Number: MED-RX-0001
Department Owner: Health Services Pharmacy
Lines of Business Affected: HealthPAC
Effective Date: January 1, 2012
Approval Date:
Revision/Reviewed Date(s):
POLICY STATEMENT
Health Care Services Agency / HealthPAC (HCSA) has an established mechanism for
reviewing and processing requests for pharmaceutical services that require prior authorization.
HCSA is committed to ensuring that all eligible HealthPAC participants have timely and
efficient access to covered pharmaceutical services that require authorization. The HealthPAC
pharmaceutical authorization process complies with the standards set by the the California
Department of Health Care Services (DHCS).
PROCEDURE
Authorization Guidelines
Outside of established Medical Home clinical practice guidelines, prior authorization is
required for the following:
1. Drugs or dosage forms that are not included in the HealthPAC formulary.
2. A branded drug when a generic is available.
HealthPAC providers are informed of the authorization process for pharmaceutical services
via the HealthPAC Provider Bulletin. Participants are informed of the HealthPAC’s prior
authorization process for pharmaceutical services via the HealthPAC’s Participant guide.
Authorization Review Requirements
Providers are responsible for using the HealthPAC formulary to submit prescription requests.
HealthPAC requires an authorization for prescriptions written where the dosage or drug is not
included on the formulary or a branded drug request when a generic equivalent is available.
Each Medical Home may use their own authorization form. However, a sample of the prior
authorization forms and written clinical practice guidelines must be submitted to HCSA upon
request and must include at a minimum the following elements:
1. Complete demographic history
2. Medication, Dosage, Quantity, Refills, Instructions for use
3. Diagnosis
4. Reason for medication request, other medications tried and/or failed, and other
pertinent medical history / diagnosis
5. Medical Necessity / or guidelines used to justify non formulary request may be
provided with the prescription.
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The HealthPAC medical home Medical Director / pharmacist / or qualified designee utilizes
criteria that have been approved by the Medical Home / Clinics Pharmacy and Therapeutics
Committee (P&T Committee). The criteria are based on evidenced based guidelines and
current literatures.
1. Initial review is completed by qualified staff Medical Director / pharmacist / or
qualified designee at the Medical Home.
2. If the Medical Home cannot arrive at a decision the request is forwarded to the
Medical Director of the Medical Home for final decision.
All decisions can be rendered by the Medical Home’s Medical Director / pharmacist / or
qualified designee under the auspices and pursuant to criteria established by plan's medical
director in collaboration with the P&T committee.
1. Reasons for denial decisions are clearly documented
Authorization Processing Timeframes
The Medical Home processes prior authorization requests for pharmaceutical services within
the following timeframes:
Decision Notification Timeframes
The Medical Home provides notification of the decision within the following timeframes:
Approvals
1. Notifications of approvals of prospective requests are made within five (5) business
days of the receipt of the requests.
2. Pharmacy Services Unit notifies the requesting Providers and pharmacy, if known, of
the approval decisions.
Denials and Modications
1. Notification of denied and modified requests include clear and concise explanations of
the reasons for the denial and a description of the criteria or guidelines used is
provided to the physician and participant within 5 business days.
2. For HealthPAC MCE (Medi-Cal Expantion) Participants: The participant’s right to,
and method of obtaining, a fair hearing to contest the denial, deferral, or modification
action and the decision the Medical Home has made including timeframes for
requesting a hearing / filing a grievence or appeal.
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Pharmacy Services
DEFINITIONS
AFFECTED DEPARTMENTS/PARTIES
RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS
1. DHCS Contract
REVISION HISTORY
REFERENCES
MONITORING
The HCSA provides oversight of its Medical Homes through an annual audit of the
authorization review process. If opportunities are identified, improvement efforts are
implemented.
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