Section 7 AAC 120.130 - Interim and final prior authorization medication lists and limitations on prescribed drugs(a) Except as provided in (c) of this section, a prescribing or dispensing provider must obtain prior authorization from the department for a medically accepted indication before dispensing a drug(1) identified on the Alaska Medicaid Prior-authorized Medicationslist, adopted by reference in 7 AAC 160.900; or(2) not identified on the Alaska Medicaid Prior-authorized Medicationslist, if (A) the drug is a new drug that the United States Food and Drug Administration approved after the publication date of that list; or(B) the department, in consultation with the drug use review committee established under 7 AAC 120.120, places the drug on an interim list of drugs for which prior authorization is required.(b) If the department requires prior authorization under (a)(2) of this section, the period for which prior authorization is required is no fewer than six months after the date that a drug described in (a)(1)(A) of this section becomes available to the market, or no fewer than six months after placement of the drug on the department's interim list, whichever period runs later.(c) In an emergency, the department will pay for no more than a five-day supply of a drug for which the department requires prior authorization under (a) of this section, and that is dispensed before the department has given prior authorization. After the drug has been dispensed, the prescribing provider must obtain prior authorization from the department. If the department authorizes payment for the dispensing of the drug, the department will include payment for the drug dispensed before the provider received prior authorization under (a) of this section. If the department does not authorize payment, the department will not pay for the drugs dispensed before the provider requested prior authorization.(d) As necessary to prevent waste or to address fraud and abuse, the department may limit its payment to minimum or maximum quantities allowed of a specific prescribed drug or a therapeutic drug class, or limit the number of refills of a specific prescribed drug or a therapeutic drug class.(e) The department may require prior authorization for a recipient based upon the recipient's previous use of drugs.(g) A provider enrolled under 7 AAC 120.100 shall provide the recipient or recipient's representative with a copy of the pamphlet titled Information About Your Prescription Drug Benefits and Prior Authorization, adopted by reference in 7 AAC 160.900, if a prescription claim is unable to process through the pharmacy claims processing system because the prescribing provider has not requested or obtained prior authorization. (h) A provider is not required under (g) of this section to provide the recipient or recipient's representative with a copy of the pamphlet if the claims processing issue is resolved the same calendar day the claim was initially unable to process through the claims processing system because the prescribing provider had not requested or obtained prior authorization. (i) If a recipient has multiple pharmacy claims that are unable to process through the claims processing system on the same date of service, the provider is only required under (g) of this section to provide the recipient or recipient's representative with one copy of the pamphlet. (j) In this section, "medically accepted indication" has the meaning given in 42 U.S.C. 1396r - 8(k)(6), adopted by reference in 7 AAC 160.900. Eff. 2/1/2010, Register 193; am 2/9/2011, Register 197; am 2/26/2015, Register 213, April 2015Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040