Current through Register No. 40, October 3, 2024
(a) Coverage of drugs subject to prior
authorization shall be in accordance with this section.
(b) Drugs shall be subject to prior
authorization based on the following:
(1) The
recommendations of the NH drug use review board made pursuant to
He-C
5010.07;
(2) The abuse potential of the
drug;
(3) Whether the drug is new
to the market;
(4) The possibility
for off-label use of the drug;
(5)
The cost of the drug; and
(6) Any
other safety or efficacy concerns.
(c) A list of drugs subject to prior
authorization shall be posted on the department's website.
(d) Prior authorization requests for a drug
shall be approved or denied based on the following:
(1) Diagnosis;
(2) Whether or not the drug is prescribed for
on or off label use;
(3)
Dosage;
(4) The recipient's age;
(5) The drug class; and
(6) Any other factor concerning safety,
efficacy, or individual recipient medical concerns.
(e) The criteria in (d) above shall be posted
on the department's website.
(f)
The procedure for requesting prior authorization shall be as follows:
(1) The licensed practitioner or their
designated agent shall initiate the prior authorization process on behalf of
the recipient by contacting the PBM by telephone or other telecommunication
device;
(2) The certified pharmacy
technician at the PBM shall collect information from the requestor in (f) (1)
above regarding the drug prescribed, to determine whether the criteria for
approval have been met;
(3) The
certified pharmacy technician at the PBM shall then either:
a. Grant immediate approval when all
criteria, as approved by the department, in accordance with (d) above have been
met; or
b. Transfer the request to
a pharmacist at the PBM when the information furnished does not satisfy the
criteria approved by the department in (d) above or when it cannot be
determined whether the criteria approved by the department in (d) above have
been met; and
(4) If the
request or caller is transferred to the pharmacist at the PBM pursuant to (f)
(3) b. above, the pharmacist shall further discuss the recipient's specific
needs with the requestor in (f) (1) above and either:
a. Grant immediate approval when all criteria
approved by the department in (d) above have been met; or
b. Issue a denial in accordance with (i)
below.
(g)
The PBM shall respond to prior authorization requests by telephone or other
telecommunication device within 24 hours of the initial request, in accordance
with Section 1927(d) (5) of the Social Security Act.
(h) While the prior authorization is being
considered, a 72-hour supply of medication shall be provided to the recipient
in an emergency, in accordance with Section 1927(d) (5) of the Social Security
Act.
(i) When a prior authorization
request is denied, the department shall forward a written letter of denial to
the recipient and the licensed practitioner that states the following:
(1) The drug being denied;
(2) The reason for the denial;
(3) The legal basis for the denial;
(4) Information on how the
recipient can file an appeal in accordance with He-C 200; and
(5) That a denial may be appealed by the
recipient within 30 calendar days from the date the denial was
issued.
(j) When a
subsequent prior authorization request is denied for a drug for which a prior
authorization was granted in accordance with (g) (1) above, the department
shall forward a written notice of denial to the recipient and the prescribing,
licensed practitioner that states the following:
(1) The drug being denied;
(2) The reason for the denial;
(3) The legal basis for the denial;
(4) Information on how the
recipient can file an appeal in accordance with He-C 200;
(5) That a denial may be appealed by the
recipient within 30 calendar days from the date the denial was issued;
and
(6) That the recipient has 10
days from the date of the written notification to request the continuation of
the original drug for which an initial prior authorization request was granted,
pending the completion of the appeal process.
(See Revision Note at chapter heading He-W 500); ss by
#5742, eff 12-1-93; ss by #5875, eff 7-27-94, EXPIRED: 7-27-00
New. #7392, eff 10-28-00; ss by
#7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02
New. #7805, eff 12-21-02; ss by
#9586, eff 11-4-09
