Policy/Procedure Title: Pharmacy TAR Procedure / ☒External Policy
☐Internal Policy /
Original Date: 04/25/1994 (Pharmacy Authorization) / Next Review Date: 11/17/2018
Last Review Date: 11/17/2017 /
Applies to: / ☒ Medi-Cal / ☐ Employees /
Policy/Procedure Number: MCRO4018 (previously RO100418) / Lead Department: Health Services /
Policy/Procedure Title: Pharmacy TAR Procedure / External Policy
Internal Policy /
Original Date: 04/25/1994 (Pharmacy Authorization) / Next Review Date: 11/17/2018
Last Review Date: 11/17/2017 /
Applies to: / Medi-Cal / Employees /
Reviewing Entities: / IQI / P & T / QUAC /
OPerations / Executive / Compliance / Department /
Approving Entities: / BOARD / COMPLIANCE / FINANCE / PAC
CEO / COO / Credentialing / DEPT. DIRECTOR/OFFICER
Approval Signature: Robert L. Moore, MD, MPH, MBA / Approval Date: 11/17/2017
I. RELATED POLICIES:
MPRP4064 - Continuation of Prescription Drugs
II. IMPACTED DEPTS:
A. Pharmacy Department
B. Member Services
C. Grievances and Appeals
III. DEFINITIONS:
N/A
IV. ATTACHMENTS:
A. N/A
V. PURPOSE:
To describe the guidelines for authorizing pharmacy Treatment Authorization Requests (TARs).
VI. POLICY / PROCEDURE:
A. Prescriptions for the following require a Treatment Authorization Request (TAR):
1. All non-formulary medications
2. Formulary drugs designated as Prior Authorization Required
3. Brand name drugs when an equivalent generic is available
4. Drugs not meeting the Code 1 restriction criteria
5. Drugs exceeding the member age, dosing limit, quantity, or duration of treatment dispensing limits
6. Any prescription that costs $1000 or more unless indicated otherwise.
7. Brand name requests in excess of a 30 day supply (added 11/20/17, for post committee review prior to PAC)
8. Scheduled drug requests in excess of a 30 day supply (added 11/20/17, for post committee review prior to PAC)
B. TAR review will be based on medical necessity. Medical necessity means reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury.
C. TARs must be requested by the provider of service by submitting an electronic TAR using the Plan’s electronic TAR submission portal (PARx) or by sending (preferably by FAX) a completed TAR form to Partnership HealthPlan of CA (PHC).
D. Documentation of Pharmacy TAR Information
1. Pharmacy Provider personnel are expected to document that the information submitted on the TAR is true, accurate and complete and the requested service is medically indicated and necessary to the health of the patient.
2. The pharmacy is expected to maintain a record that verifies the information submitted on the TAR was provided by the prescriber or the prescriber’s representative.
3. Specifically, the pharmacy is expected to confirm a treatment failure with the formulary alternative prior to requesting a non-formulary medication because of a treatment failure with the formulary alternative. The pharmacy is expected to keep written documentation of this information.
Added 11/20/17, for post committee review prior to PAC:
4. Requests for brand name drugs in excess of a 30 day supply should include reasons why a monthly fill is a hardship for the member. When hardship exists, approval will be considered for non-scheduled drugs that are for maintenance of a chronic condition and claim history or notes submitted indicate member is dose-stable and tolerating the current regimen.
5. Scheduled drugs (brand or generic): requests for greater than a 30 day supply will be reviewed on a case-by-case basis and will be considered for approval only for one time fill when extenuating circumstances exist and allowing greater than a 30 day supply is medically necessary, as defined in VI.B above.
E. The PHC Clinical Pharmacist, Pharmacy Technician, Pharmacy Director, or Registered Nurse HealthPlan staff will perform all initial TAR reviews. All reviews by the Pharmacy Technician adhere to PHC written criteria and are performed under supervision of a HealthPlan pharmacist.
F. References used to determine authorization decisions shall include, but are not be limited to:
1. Medical references which list FDA labeling information including current editions of the Physicians’ Desk Reference, Drug Facts & Comparisons, USP Drug Information for the Health Care Professional, and other references as available on the internet.
2. PHC prior authorization criteria.
3. PHC Clinical Practice Guidelines.
4. Consultation with the Medical Director and/or outside consultants.
G. The PHC Clinical Pharmacist, Pharmacy Technician, Pharmacy Director, or Registered Nurse HealthPlan staff reviewer may take the following TAR actions:
1. Approve: An approved TAR is a TAR approved for the requested drug, strength and quantity. If the reviewer changes the units (# of fills) requested or date of service, this is still considered an approved TAR.
2. Approve as Modified (PHC Clinical Pharmacist and Pharmacy Director only): A modified TAR is a TAR that is approved with a total Rx quantity or a different daily dose quantity that differs from the requested quantity &/or day supply submitted by the provider. The reviewer may approve a TAR as Modified on the basis of their clinical judgment without consultation from the Medical Director.
3. Administrative Denials are based on the following administrative criteria:
a. TAR not required.
b. Carve-out drug.
c. Member not eligible with PHC on date of service.
d. Duplicate request.
e. Member has other primary pharmacy insurance.
f. TAR not submitted on a timely basis.
g. Insufficient information submitted on the TAR to further review (PHC Clinical Pharmacist and Pharmacy Director only).
H. The Chief Medical Officer (CMO) or Medical Director must be available, physically or by telephone, during business hours to assist with the review of TARs.
1. CMO/Medical Director reviews may be requested by the Clinical Pharmacist in cases of potential denial due to questionable medical necessity or inappropriate use of a drug.
2. The CMO/Medical Director may contact the prescribing physician and/or consultants for additional information, as required, to assist him/her in rendering a decision about the case.
3. The CMO/Medical Director and Clinical Pharmacists can authorize denials based on medical criteria or make any exceptions/changes to the established medical policy for pharmacy management.
4. The CMO/Medical Director and Clinical Pharmacists can authorize denials for products which the HealthPlan and P & T Committee, in accordance with DHCS guidelines, has determined a product is not a covered benefit.
5. The CMO/Medical Director and Clinical Pharmacists can authorize denials based on DHCS issued instructions (OILs, APLs or Emails) that a product is not a covered benefit.
6. If the CMO/Medical Director is not available, he/she may designate another physician or Clinical Pharmacist to fulfill the requirements under H 1, 2, 3.
I. Determination and provider notification by telephone, FAX or other telecommunication device of PHC determinations will be made within twenty-four (24) hours of receiving a completed TAR.
J. Determination and provider notification of PHC determinations for urgent TARs will be made within twenty-four (24) hours from the date and time the TAR is received. The Plan will make every effort to provide determination and both provider and member notification for urgent TARs, if the TAR is received by 3:00 PM on a Plan business day. All TARs received by PHC designated as urgent by the submitting provider are subject to review to determine if the TAR should be processed as urgent.
K. Determination and member notification of PHC determinations, which includes the reason for the denial, deferral, or modification and information about the appeals process, is made within one (1) working day of the following TAR actions:
1. A denied TAR that lacks medical justification for the intended use of the drug.
2. A denied TAR that lacks documentation of having met PHC criteria for use and lacks medical justification for an approval outside of PHC criteria.
3. A denied TAR in which insufficient information was submitted on the TAR.
4. A denied TAR in which the requested drug is a Carve-out drug (member notification is administrative and not a determination of medical necessity).
5. A denied TAR in which the member has other primary insurance (member notification is administrative and not a determination of medical necessity).
6. A denied TAR in which the requested product is not a covered benefit
7. A modified TAR.
L. Emergency TARs outside of PHC’s normal business hours:
1. During PHC’s normal business hours (M-F 8 AM to 5 PM), pharmacies may call the PHC Pharmacy Department for an emergency 5 day fill. The pharmacy department may authorize up to a 5-day supply of medication, pending further authorization by PHC if the Pharmacy Department is not able to determine the medical necessity of the full prescription.
2. Outside of PHC’s normal business hours PHC’s contracted Pharmacy Benefit Manager (PBM) is authorized to respond to emergency TARs outside of PHC’s normal business hours, including weekends and holidays. The PBM may authorize up to a 5-day supply of medication, pending further authorization by PHC.
3. When both PHC and the contracted PBM are unavailable, PHC will authorize a retroactive TAR allowing the pharmacy to dispense up to a 5 day supply of a non-formulary drug.
M. Retroactive TARs must be received by PHC within fifteen (15) business days of requested date of service. Retroactive TARs received after fifteen (15) business days of requested date of service may be considered for review under the following conditions:
1. When certification of the Medi-Cal beneficiary’s eligibility by the county welfare department was delayed.
2. When other coverage (e.g., Medicare or other health insurance programs) denied payment of a claim for services.
3. When a member does not identify himself/herself to the provider as a PHC member by deliberate concealment or because of physical or mental incapacity to so identify himself/herself.
4. If a member has obtained retroactive eligibility, the TAR must be received by PHC within 60 days of the members obtaining Medi-Cal eligibility.
N. TAR approval will be granted for a member to continue the use of a non-formulary single source drug which is part of a prescribed therapy in effect before enrollment with PHC until the therapy is no longer prescribed by the member’s doctor as described in Policy #MPRP4064 Continuation of Prescription Drugs.
VII. REFERENCES:
N/A
VIII. DISTRIBUTION:
A. PHC Department Directors,
B. PHC Provider Manual
C. Policies & Procedures SharePoint site
IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:
Associate Director of Pharmacy Operations
X. REVISION DATES: 03/23/95; 10/10/97 (name change only); 05/28/99; 12/15/99, 10/17/01; 04/17/02; 11/20/02; 11/19/03; 04/21/04; 04/3/08; 01/27/11; 08/18/11; 01/17/13; 01/16/14; 10/1/15; 10/6/16; 04/06/17, 11/17/2017
PREVIOUSLY APPLIED TO:
N/A
XI. POLICY DISCLAIMER:
A. In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:
1. Consistent with sound clinical principles and processes;
2. Evaluated and updated at least annually;
3. If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request.
B. The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.
C. PHC’s authorization requirements comply with the requirements for parity in mental health and substance use disorder benefits in 42 CFR 438.910.
Page 4 of 4