Oklahoma § 63-5030.5 - Drug prior authorization program - Conditions

§ 63-5030.5. Drug prior authorization program - Conditions

A. Except as provided in subsection F of this section, any drug

prior authorization program approved or implemented by the Medicaid

Drug Utilization Review Board shall meet the following conditions:

1. The Medicaid Drug Utilization Review Board shall make note

of and consider information provided by interested parties,

including, but not limited to, physicians, pharmacists, patients,

and pharmaceutical manufacturers, related to the placement of a drug

or drugs on prior authorization;

2. Any drug or drug class placed on prior authorization shall

be reconsidered no later than twelve (12) months after such

placement;

3. The program shall provide either telephone or fax approval

or denial within twenty-four (24) hours after receipt of the prior

authorization request; and

4. In an emergency situation, including a situation in which an

answer to a prior authorization request is unavailable, a seventytwo-hour supply shall be dispensed, or, at the discretion of the

Medicaid Drug Utilization Review Board, a greater amount that will

assure a minimum effective duration of therapy for an acute

intervention.

B. In formulating its recommendations for placement of a drug

or drug class on prior authorization to the Oklahoma Health Care

Authority Board, the Medicaid Drug Utilization Review Board shall:

1. Consider the potential impact of any administrative delay on

patient care and the potential fiscal impact of such prior

authorization on pharmacy, physician, hospitalization and outpatient

costs. Any recommendation making a drug subject to placement on

prior authorization shall be accompanied by a statement of the cost

and clinical efficacy of such placement;

Oklahoma Statutes - Title 63. Public Health and Safety

2. Provide a period for public comment on each meeting agenda.

Prior to making any recommendations, the Medicaid Drug Utilization

Review Board shall solicit public comment regarding proposed changes

in the prior authorization program in accordance with the provisions

of the Oklahoma Open Meeting Act and the Administrative Procedures

Act; and

3. Review Oklahoma-Medicaid-specific data related to

utilization criterion standards as provided in division (1) of

subparagraph b of paragraph 2 of Section 5030.4 of this title.

C. The Oklahoma Health Care Authority Board may accept or

reject the recommendations of the Medicaid Drug Utilization Review

Board in whole or in part, and may amend or add to such

recommendations.

D. The Oklahoma Health Care Authority shall immediately provide

coverage under prior authorization for any new drug approved by the

United States Food and Drug Administration. If a new drug does not

fall in a class that is already placed under prior authorization,

that drug must be reviewed by the Drug Utilization Review Board

within one hundred (100) days of approval by the United States Food

and Drug Administration to determine whether to continue the prior

authorization criteria.

E. 1. Prior to a vote by the Medicaid Drug Utilization Review

Board to consider expansion of product-based prior authorization,

the Authority shall:

a.

develop a written estimate of savings expected to

accrue from the proposed expansion, and

b.

make the estimate of savings available, on request of

interested persons, no later than the day following

the first scheduled discussion of the estimate by the

Medicaid Drug Utilization Review Board at a regularly

scheduled meeting.

2. The written savings estimate based upon savings estimate

assumptions specified by paragraph 3 of this subsection prepared by

the Authority shall include as a minimum:

a.

a summary of all paid prescription claims for patients

with a product in the therapeutic category under

consideration during the most recent month with

complete data, plus a breakdown, as available, of

these patients according to whether the patients are

residents of a long-term care facility or are

receiving Advantage Waiver program services,

b.

current number of prescriptions, amount reimbursed and

trend for each product within the category under

consideration,

c.

average active ingredient cost reimbursed per day of

therapy for each product and strength within the

category under consideration,

Oklahoma Statutes - Title 63. Public Health and Safety

d.

for each product and strength within the category

under consideration, where applicable, the prevailing

State Maximum Allowable Cost reimbursed per dosage

unit,

e.

the anticipated impact of any patent expiration of any

product within the category under consideration

scheduled to occur within two (2) years from the

anticipated implementation date of the proposed prior

authorization expansion, and

f.

a detailed estimate of administrative costs involved

in the prior authorization expansion including, but

not limited to, the anticipated increase in petition

volume.

3. Savings estimate assumptions shall include, at a minimum:

a.

the prescription conversion rate of products requiring

prior authorization (Tier II) to products not

requiring prior authorization (Tier I) and to other

alternative products,

b.

aggregated rebate amount for the proposed Tier I and

Tier II products within the category under

consideration,

c.

market shift of Tier II products due to other causes

including, but not limited to, patent expiration,

d.

Tier I to Tier II prescription conversion rate, and

e.

nature of medical benefits and complications typically

seen with products in this class when therapy is

switched from one product to another.

4. The Medicaid Drug Utilization Review Board shall consider

prior authorization expansion in accordance with the following

Medicaid Drug Utilization Review Board meeting sequence:

a.

first meeting: publish the category or categories to

be considered for prior authorization expansion in the

future business section of the Medicaid Drug

Utilization Review Board agenda,

b.

second meeting: presentation and discussion of the

written estimate of savings,

c.

third meeting: make formal notice in the agenda of

intent to vote on the proposed prior authorization

expansion, and

d.

fourth meeting: vote on prior authorization

expansion.

F. The Medicaid Drug Utilization Review Board may establish

protocols and standards for the use of any prescription drug

determined to be medically necessary, proven to be effective and

approved by the United States Food and Drug Administration (FDA) for

the treatment and prevention of human immunodeficiency

virus/acquired immune deficiency syndrome (HIV/AIDS) without prior

Oklahoma Statutes - Title 63. Public Health and Safety

authorization, except when there is a generic equivalent drug

available.

Added by Laws 1999, c. 201, § 5, eff. July 1, 1999. Amended by Laws

2001, c. 340, § 1, emerg. eff. June 1, 2001; Laws 2002, c. 411, § 2,

emerg. eff. June 5, 2002; Laws 2005, c. 206, § 1, eff. Nov. 1, 2005;

Laws 2014, c. 341, § 1, eff. July 1, 2014; Laws 2015, c. 306, § 1.