Prescriber Prevails in Medicaid Managed Care for Atypical Antipsychotics
Effective January 1, 2013, Medicaid Managed Care Plans will be required to implement “prescriber prevails” for medically necessary prescription drugs in the atypical antipsychotic therapeutic drug class. This change is the result of legislation passed in the 2012-2013 Executive Budget. Once implemented, this initiative will enable the prescriber's reasonable professional judgment to prevail in the prior authorization process for atypical antipsychotics.
Plans will continue to develop formularies and may also administer prior authorization programs for atypical antipsychotics. Prescribers will still be required to provide plans with requested information and/or clinical documentation to support prior authorization requests. As they do currently, plans may provide a temporary (3 day) supply of medication when medically necessary.
Plans are required to meet specific federal determination timeframes in response to requests for health care services. Consistent with these requirements, when the plan is unable to complete a prior authorization due to missing information or because the prescriber’s reasonable professional judgment has not been adequately demonstrated, either by consistency with FDA approved labeling or use supported in at least one of the Official Compendia as defined in federal law under the Social Security Act section 1927 (g)(1)(B)(i), the plan will issue a notice of action to the provider and member. Such notice will describe the information required to complete the authorization and the member’s rights regarding appeals and fair hearings.