Prescription drugs

On this page, you’ll find information on OIC rules adopted in 2015 governing the prior authorization processes for prescription drugs.

The term “physician” is used on this page primarily for convenience. Other categories of health professionals may also be affected by the new rule. In some case, it may be appropriate to delegate certain actions to non-clinical staff.

TPA = Third-party administrator

Background
Drug utilization review program requirements
Types of prior authorization and timeframes
Determination notification requirements
Formulary changes
Emergency fills
Enforcement
Third-party administrators

 

Background

The OIC adopted rules in 2015 implementing recommendations of a workgroup convened by OneHealthPort aimed at improving prior authorization processes for prescription drugs.

Drug utilization review program requirements

Insurance carriers are required to maintain a documented drug utilization review program that:

• Meets certification standards used by the National Committee for Quality Assurance.
• Has staff who are properly qualified, trained, supervised and supported by explicit written clinical review criteria and review procedures.

Program documentation must be made available upon request by a physician.

Types of prior authorization and timeframes

To ensure timely processing of prior authorization requests, insurance carriers and TPAs are required to have written program procedures.

Non-urgent care review requests
Insurance carriers must make a determination and provide notification on a non-urgent care review request within five calendar days.

If insufficient information is provided to approve or deny a claim, insurance carriers have five calendar days to request the information needed to make the determination. The physician then has five calendar days to submit the requested information; once received, insurance carriers then have four calendar days to process the request.

Urgent care review requests
Insurance carriers must make a determination and provide notification on an urgent care review request within 48 hours.

If insufficient information is provided to approve or deny a claim, insurance carriers have 24 hours to request the information needed to make the determination. The physician then has 48 hours to submit the requested information; once received, insurance carriers then have 48 hours to process the request.

Determination notification requirements

Determinations from insurance carriers must include whether the request was approved. Insurance carriers must notify the requesting physician by phone, fax and/or secure electronic notification, and notify the patient in writing or via secure electronic notification. Timeframes for sending this notification must mirror the timeframes for the urgent and non-urgent requests discussed above.

Formulary changes

Insurance carriers are required to make current formulary information electronically available for loading into electronic health records using the formulary and benefit standard transaction of the National Council for Prescription Drug Programs. The following information must be provided by an insurance carrier:

• Tier level
• Contract exclusions
• Quantity limits
• Preauthorization required
• Preferred/step therapy

Emergency fills

An “emergency fill” means a limited dispensed amount of medication that allows time for the processing of a preauthorization request. An emergency fill only applies to those circumstances where a patient presents at a contracted pharmacy with an immediate therapeutic need for a prescribed medication that requires a prior authorization.

An insurer must post its emergency fill policy online and provide the inclusionary and exclusionary list of medications eligible for emergency fill. The authorized amount of emergency fill will be no more than the amount prescribed, up to a seven-day supply or the minimum packaging size available.

Prior authorization determinations must be transmitted to the requesting party and must include information about whether or not the request was approved. If the request is made by a pharmacy, notification must also go to the prescriber. An approval must also include a statement from the carrier indicating it will authorize an emergency fill by the dispensing pharmacist if they are unable to reach an insurance carrier’s utilization review outside of normal business hours, or if a carrier is able to respond but does not reach the prescriber for a full consultation.

The OIC clarifies that an emergency fill does not necessarily constitute a covered health service; this determination will be made as part of the utilization review processes. The rule makes clear that insurance carriers are prohibited from penalizing or threatening to reduce payment or terminate a physician’s participation status because of the physician’s dispute of the insurance carrier’s determination with respect to coverage or payment for pharmacy services.

Enforcement

The WSMA strongly encourages physicians to file a complaint with the OIC when they experience an insurance carrier or third party administrator not conducting drug utilization programs in accordance with the 2015 rule. File a complaint with the OIC using the WSMA Prior Authorization Navigator’s complaint form or by calling 800.562.6900.

Third-party administrators

The rule states: “Every issuer must be responsible for ensuring that any person acting on behalf of or at the direction of the issuer or acting pursuant to carrier standards or requirements complies with these transaction standards.”