Section 16.03.09.663 - PRESCRIPTION DRUGS: PROCEDURAL REQUIREMENTSIn accordance with Section 1927(d)(1)(A) of the Social Security Act, the Idaho Medicaid Pharmacy Program may subject any covered outpatient drug to prior authorization.
01.Drugs Requiring Prior Authorization. No payment for drugs requiring prior authorization will be issued until the prior authorization request has been reviewed and approved by the Department.02.Prior Authorization Criteria. Criteria for prior authorization for individual drugs and drug classes will be determined by the Department, and will include: a. Food and Drug Administration (FDA) indications and labeling, including dosage guidelines.b. Compendia of drug information recognized by the Centers for Medicare and Medicaid Services (CMS), including: i. American Hospital Formulary Service-Drug Information;ii. United States Pharmacopeia-Drug Information, or its successor publications; andiii. The DrugDex Information System.c. Evidence-based, peer-reviewed, published medical literature, including: ii. Randomized controlled trials; andiii. Meta-analysis studies.d. Guidelines and case-controlled studies may be considered where systematic reviews, randomized controlled trials and meta-analysis studies do not exist.e. The requested drug's preferred drug status.03.Request for Prior Authorization.a. The prior authorization procedure is initiated by the prescriber who must submit the request to the Department in the format prescribed by the Department.b. Whenever possible, the Department will use automated authorization, in which claims are adjudicated at point of sale using submitted National Council for Prescription Drug Programs (NCPDP) data elements or claims history to verify that the Department's authorization requirements have been satisfied, without the need for the prescriber to submit additional clinical information.04.Notice of Decision. The Department will determine coverage based on this request, and will notify the participant of a denial. The participant has twenty-eight (28) days from the date the denial letter is mailed to appeal the decision. Hearings will be conducted in accordance with IDAPA 16.05.03, "Contested Case Proceedings and Declaratory Rulings."05.Emergency Situation. The Department will provide for the dispensing of at least a seventy-two (72) hour supply of a covered outpatient prescription drug in an emergency situation as required in 42 U.S.C. 1396r-8(d)(5)(B).06.Response to Request. The Department will respond within twenty-four (24) hours to a request for prior authorization of a covered outpatient prescription drug as required in 42 U.S.C. 1396r-8(d)(5)(A).07.Prohibition Against Cash Payment for Controlled Substances. Pharmacy providers are prohibited from accepting cash as payment for controlled substances from persons known to be Medicaid participants.08.Supplemental Rebates. a. Purpose. The purpose of supplemental rebates is to enable the Department to purchase prescription drugs provided to Medicaid participants in a cost-effective manner. The supplemental rebate may be one (1) factor considered in determining a drug's preferred drug status, but it is secondary to considerations of the safety, effectiveness, and clinical outcomes of the drug in comparison with other therapeutically interchangeable alternative drugs.b. Rebate Amount. The Department may negotiate with manufacturers supplemental rebates for prescription drugs that are in addition to those required by Title XIX of the Social Security Act. There is no upper limit on the dollar amounts of the supplemental rebates the Department may negotiate.09.Comparative Costs to be Considered. Whenever possible, physicians and pharmacists are encouraged to utilize less expensive drugs and drug therapies.Idaho Admin. Code r. 16.03.09.663