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Drug Authorizations

Revised: 02-17-2016

MHCP currently contracts with Health Information Designs (HID) to process authorization requests for covered outpatient prescription and physician-administered drugs that require authorization.

Pharmacies and prescribing providers must submit all drug authorization requests to HID, the MHCP prescription drug prior authorization (PA) agent, by phone at 866-205-2818 or fax 866-648-4574.

  • • MHCP prescription drug prior authorization call center hours are 8:00 a.m. to 5:30 p.m. Monday through Friday, except select holidays.
  • • Prescribing providers must include the drug name, dosage, prescriber NPI, the pharmacy name and phone number on the authorization request. The NDC number and pharmacy NPI is optional for prescribers. The MHCP prescription drug prior authorization (PA) agent will make outbound calls to the pharmacy to determine NDC and pharmacy NPI, as needed.
  • • Outside of MHCP prescription drug PA call center hours, pharmacists may dispense up to a 72-hour supply of a covered prescribed medication requiring authorization. (The MHCP prescription drug PA agent will authorize after the fact.) However, the MHCP prescription drug PA agent will not authorize additional supplies if authorization criteria are not met.
  • • Only health care providers may request authorizations; the MHCP prescription drug PA agent will deny authorization requests submitted by agents of drug manufacturers.
  • Authorization with third-party liability

    The MHCP prescription drug PA agent will not review a request for authorization when a recipient has other prescription drug coverage, unless the provider has made a good faith effort to obtain the maximum available payment from the other payer and provides documentation of that effort.

    If the authorization request is approved, MHCP will pay for the copay or coinsurance amount, up to the MHCP allowed amount.

    The MHCP point-of-sale claims system will bypass the prior authorization requirement when the third party insurance has paid 60% or more of the MHCP allowed amount of the prescription. Pharmacies must submit the other payer amount paid in the 431-DV field of the NCPDP D.0 claim in order to bypass the prior authorization requirement.

    If the third party has not paid at least 60% of the cost of the prescription, the provider must supply one of the following before the MHCP prescription drug PA agent will review the request against the following clinical criteria:

  • • Verification of coverage and documentation of payment amount from the third-party payer. Acceptable documentation includes:
  • • Screen shot of the claim in pharmacy system showing third party paid amount. The third party paid amount must be greater than $0.00
  • • Prior authorization or formulary exception approval letter or fax from primary insurance
  • • Verification of noncoverage of the prescription from the third party payer. Noncoverage documentation must include:
  • • Third party payer’s rationale for denial, as provided through a formulary exception denial letter, an appeal determination letter, or a plan benefit document showing that the class of drug requested is excluded from coverage and
  • • Prescriber’s rationale of why the third party’s formulary or preferred drug cannot be used
  • Providers do not need to submit a prior authorization request for office administered drugs if the primary payer is Medicare. MHCP will pay for the coinsurance amount, up to the MHCP allowed amount, without authorization.

    The MHCP prescription drug PA agent is working to allow pharmacies and prescribing providers to be able to complete an electronic authorization request through a secure link to the PAXpressTM application. Staff at the MHCP prescription drug PA call center have access to prescription and medical claims history. Providers will still have the option to call or fax authorization requests to the MHCP prescription drug PA agent.

    The PA agent is also working to allow select prescriptions to be electronically processed at the point of sale (POS) without the provider having to submit an authorization request.

    Continue to submit authorization requests for medical supplies (including diabetic supplies) to the medical review agent. Direct only drug prior authorization requests tothe prescription drug PA agent.

    Additional Resources

    MHCP Pharmacy Quick Reference

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