317:30-5-77.2. Prior authorization
(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 pharmacoeconomic 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.