A snapshot of Medication Prior Authorization (PA): a program of the Georgia Department of Community Health [Jan. 2011]

A Program Of The Georgia Department Of Community Health
A SNAPSHOT OF GEORGIA
Medication Prior Authorization
Overview
Medication Prior Authorization (PA) programs are designed to ensure clinically appropriate and cost-effective use of medications. A programs provide access to necessary medications in a manner that is compliant with the medications' FDA-approved use and or with national guidelines, evidence based medicine, or nationally recognized standards of therapy. This process is also necessary in the public sector to demonstrate compliance with federal fiduciary and oversight requirements. PA programs are highly effective tools used to ensure quality and decrease costs when supported by clinical evidence.
This process provides an additional step in promoting patient safety and positive clinical outcomes.
Importance of Prior Authorization Programs
PA is necessary to ensure: Clinical appropriateness; Drug safety and avoidance of drug to drug interactions; Reduction in medication errors; Compliance with nationally recognized clinical guidelines from national medical associations and standards of practice; Appropriate monitoring and control of utilization of new drugs or new uses for existing medications; prevent fraud and diversion; Detection of patients receiving duplicate or unnecessary medication therapies from multiple prescribers; Detection and prevention of substance abuse; and Compliance with federal requirements that states Federal Financial Participation (FFP) is dependent on "...methods of administration that are...necessary for the proper and efficient operation of the plan..." 42CFR 431.15. PA is an important tool for appropriate fiscal management, fraud prevention, and to meet federal oversight requirements.
Current Medicaid Prior Authorization Request Process
PA request from the physician or pharmacist Request can be made via several methods (phone, fax or written) The Pharmacy Benefits Manager (PBM) applies the Georgia Department of Community Health (DCH)-
approved clinical criteria
Claim may be: Approved. Approvals are entered into the system and available immediate claims processing
Denied. All denial requests are accompanied by the PBM representative offering the DCH appeal process All providers whose request has been denied receive a denial letter with the offer of the appeal process

January 2011

2 Peachtree Street, Atlanta, Ga 30303 w www.dch.georgia.gov

A Snapshot Of Medication Prior Authorization
Pended. A request may be pended if further documentation is needed from the physician's office All pended requests for which the follow-up documentation is not received within 72 hours are denied The PBM attempts three follow-up contacts with the physician within that 72 hour period to obtain the necessary information All PA requests are either approved, denied, or pended within one business day of receipt
A first- and second-level appeal process is available. First-level Medicaid appeals are reviewed by a pharmacist at the PBM or a DCH Pharmacist depending on the drug being requested All second-level Medicaid appeals are reviewed by a DCH Pharmacist Written disposition of the appeal request is provided to the physician Medicaid first-level appeal requests are addressed within 48 hours of receipt. Second-level appeal requests are addressed within 72 hours of receipt
SPECIAL NOTE - Emergency override process is available to ensure access to necessary medications.
Prior Authorization Decision Process
DCH monitors new drugs to market and utilization patterns of existing drugs
The Drug Utilization Review (DUR) Board evaluates all new drugs after the drug has six months of market experience and makes recommendations to DCH. In the interim six months, DCH may or may not implement a PA depending on the characteristics of the individual drug
DUR Board evaluates all supplemental rebate drug categories on an annual basis and makes recommendations to DCH
Candidates for PA include but are not limited to:
Drugs with niche indications
Drugs that are not first line therapies
Drugs with significant safety concerns
Drugs with less costly therapeutic alternatives
Clinical literature is evaluated
PA criteria is developed and approved by DCH
Notice is given to providers via banner messaging
PA criteria is published on the web
PA process implemented
Post-implementation monitoring and evaluation