Provider Notice issued 01/30/13

Four Prescription Policy – Continued Implementation

Effective February 4, 2013, the department will reduce the number of prescriptions that can be filled in a thirty-day period without prior authorization from seven to five. In addition, the department will begin to phase-in prescriptions for patients residing in long-term care facilities (LTC), including participants residing in community-based long-term care settings.

Long Term Care

Effective February 4, 2013, prior approval will be required for a LTC resident's prescriptions after the resident has filled five prescriptions in the preceding 30 day period. Federal Regulations at 42 C.F.R. §483.60 (pdf) require LTC facilities employ or obtain the services of a licensed pharmacist to provide consultation on all aspects of the provision of pharmacy services in the facility, including a drug regimen review at least once a month for each facility resident. Because medication regimens are already being reviewed for LTC residents, the Department will allow pharmacies, rather than the prescribers, to submit the Four Prescription Policy prior approval requests (PA). Prior to submitting a PA request, the pharmacists should conduct a review of a patient's complete medication regimen and request a Four Script Policy Prior Authorization for all drugs that the patient should continue. In cases where patients are receiving inappropriate therapy, including but not limited to, off-label use of a drug where there is no literature to support its use for the condition being treated; duplicate therapy, meaning more than one medication that has the same therapeutic effect to treat the same condition; or doses that exceed a product's labeled dosing limitations, the pharmacist must include 1) a summary of the communication to the prescriber alerting the prescriber of the therapeutic duplication and the date of notification, 2) a summary of the prescriber's response including their clinical justification for the prescribing, and 3) a plan for altering the medication therapy if the change is being made over an extended period of time to allow for titration.

Prior Approval Requests

Prescribers are strongly encouraged to enter prior approval requests using the Medical Electronic Data Interchange (MEDI) System. To simplify the prior authorization request process, the Department has added the Four Prescription Policy Override Request Form to the MEDI system. Requests entered into the MEDI system go directly into the Department's drug prior approval adjudication database for review by a physician or pharmacist. Requests that are faxed to the Department's Prior Approval Hotline must be data entered after receipt. Prior approval requests are typically reviewed within two hours of being entered into the adjudication database, but can take longer. The MEDI system also allows prescribers to easily check the status of a prior approval request that was entered through the MEDI system, by using the prior authorization number that was assigned when the request was entered. More information about registering for MEDI, and requesting prior approval through the MEDI system, is available on the Department's MEDI Web site.

As indicated previously, certain drugs do not require prior approval under the Four Prescription Policy; therefore, prescribers should not request prior approval for those drugs. Drugs that do not require prior approval are listed on our Four Prescription Policy Web page.

Questions regarding this notice should be directed to the Bureau of Pharmacy Services at 1-877-782-5565, Option 7.

Theresa A. Eagleson, Administrator

Division of Medical Programs