Section He-W 570.06 - Prior Authorization(a) Coverage of drugs subject to prior authorization shall be in accordance with this section.(b) Drugs shall be subject to prior authorization based on the following: (1) The recommendations of the NH drug use review board made pursuant to He-C 5010.07;(2) The abuse potential of the drug;(3) Whether the drug is new to the market;(4) The possibility for off-label use of the drug;(5) The cost of the drug; and(6) Any other safety or efficacy concerns.(c) A list of drugs subject to prior authorization shall be posted on the department's website.(d) Prior authorization requests for a drug shall be approved or denied based on the following: (2) Whether or not the drug is prescribed for on or off label use;(6) Any other factor concerning safety, efficacy, or individual recipient medical concerns.(e) The criteria in (d) above shall be posted on the department's website.(f) The procedure for requesting prior authorization shall be as follows: (1) The licensed practitioner or their designated agent shall initiate the prior authorization process on behalf of the recipient by contacting the PBM by telephone or other telecommunication device;(2) The certified pharmacy technician at the PBM shall collect information from the requestor in (f) (1) above regarding the drug prescribed, to determine whether the criteria for approval have been met;(3) The certified pharmacy technician at the PBM shall then either: a. Grant immediate approval when all criteria, as approved by the department, in accordance with (d) above have been met; orb. Transfer the request to a pharmacist at the PBM when the information furnished does not satisfy the criteria approved by the department in (d) above or when it cannot be determined whether the criteria approved by the department in (d) above have been met; and(4) If the request or caller is transferred to the pharmacist at the PBM pursuant to (f) (3) b. above, the pharmacist shall further discuss the recipient's specific needs with the requestor in (f) (1) above and either: a. Grant immediate approval when all criteria approved by the department in (d) above have been met; orb. Issue a denial in accordance with (i) below.(g) The PBM shall respond to prior authorization requests by telephone or other telecommunication device within 24 hours of the initial request, in accordance with Section 1927(d) (5) of the Social Security Act.(h) While the prior authorization is being considered, a 72-hour supply of medication shall be provided to the recipient in an emergency, in accordance with Section 1927(d) (5) of the Social Security Act.(i) When a prior authorization request is denied, the department shall forward a written letter of denial to the recipient and the licensed practitioner that states the following: (1) The drug being denied;(2) The reason for the denial;(3) The legal basis for the denial; (4) Information on how the recipient can file an appeal in accordance with He-C 200; and(5) That a denial may be appealed by the recipient within 30 calendar days from the date the denial was issued.(j) When a subsequent prior authorization request is denied for a drug for which a prior authorization was granted in accordance with (g) (1) above, the department shall forward a written notice of denial to the recipient and the prescribing, licensed practitioner that states the following: (1) The drug being denied;(2) The reason for the denial;(3) The legal basis for the denial; (4) Information on how the recipient can file an appeal in accordance with He-C 200;(5) That a denial may be appealed by the recipient within 30 calendar days from the date the denial was issued; and(6) That the recipient has 10 days from the date of the written notification to request the continuation of the original drug for which an initial prior authorization request was granted, pending the completion of the appeal process.N.H. Admin. Code § He-W 570.06
(See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93; ss by #5875, eff 7-27-94, EXPIRED: 7-27-00
New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02
New. #7805, eff 12-21-02; ss by #9586, eff 11-4-09
Amended by Volume XXXVII Number 50, Filed December 14, 2017, Proposed by #12421, Effective 11/21/2017, Expires 5/20/2018.Amended by Volume XXXVIII Number 23, Filed June 7, 2018, Proposed by #12529, Effective 5/22/2018, Expires 5/22/2028.