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District of Columbia Medical Assistance Administration Expedited Prior Authorization Pharmacy Guidance NOTE: As of October 1, 2008, the Medical Assistance Administration will become the Department of Health Care Finance. Topics. Introduction Scope & Objective of this training
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District of Columbia Medical Assistance AdministrationExpedited Prior AuthorizationPharmacy Guidance NOTE: As of October 1, 2008, the Medical Assistance Administration will become the Department of Health Care Finance
Topics • Introduction • Scope & Objective of this training • Overview of DC MAA Prior Authorizations • Overview of Expedited PA process • DC ACS Call Center Information • Pharmacy Practice Pearls • Questions & Concerns
Scope and Objective • DC Medical Assistance Administration (MAA) Prior Authorizations are in accordance with Federal Regulation 42 U.S.C. 1396r-8(g)(2) • MAA reserves the right to monitor all participating entities to ensure compliance with the policies and procedures as outlined in the PA Guidance document. • The MAA Prior Authorization Guidance will be posted on the DC PBM Website at www.dcpbm.com • The objective of this training is to clearly define the prior authorization policy and the procedures for the Expedited PA’s
Overview of DC MAA Prior Authorizations MAA has developed several prior authorization protocols for use in the medication management program. They are: • Expedited Prior Authorization (E-PA) These are for PAs that are generated by prescriptions from emergency facilities and Urgent Care centers • Narcotic Prior Authorizations (N-PA) These are PAs for Schedule II medications intended for long-termuse • Medication Therapy Management Prior Authorization (MTM-PA) This category include the medication therapy management protocols implemented by MAA in other programs including the following:
Overview of DC MAA Prior Authorizations(Continued) • Preferred Drug List (PDL) • Opioid narcotics and narcotic combinations • Anti-ulcer therapy • Injectables • Hepatitis C medications • Growth hormone therapy • Synagis These and other ongoing PA 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.
Overview of Expedited Prior Authorization Process The dispensing pharmacist may verbally request a one-time PA for a Schedule II narcotic medication when a prescription is generated by: • An emergency facility, such as a hospital emergency room • Urgent care center. This PA process is not intended for • long-term use • more than two Schedule II narcotic prescriptions presented at one time • for prescription quantities greater than a seven (7) day supply. The DUR agent at the Pharmacy Call Center can authorize a one-time PA for such emergency use without having to contact the prescribing physician.
DC MAA Call Center Information • ACS will provide assistance to providers and recipients through the ACS Pharmacy Call Center at 1-800-272-9679 • ACS will provide clinical prior authorizations through the ACS Pharmacy Call Center at 1-800-273-4962 • The dispensing pharmacist can call the ACS Pharmacy Call Center at 1-800-273-4962 to request a one-time PA for such use when this emergency criterion is met. • Clinical /PDL PA request form can be faxed to the ACS Pharmacy Call Center at 1-866-535-7622. The forms are available at www.dcpbm.com.
Pharmacy Practice Pearls • An Expedited PA process is now available. • Always call the ACS Call Center for assistance. • Please do not send DC Medicaid recipients away without talking to the ACS Call Center. • Thank you for your continuing partnership.
