Scope of drug benefits - Prior authorization.

75-02-02-27. Scope of drug benefits - Prior authorization. 1. Prior authorization means a process requiring the prescriber or the dispenser to verify with the department or the department's contractor that proposed medical use of a particular drug for a Medicaid program or children's health insurance program recipient meets predetermined criteria for coverage by the Medicaid program or children's health insurance program. 2. A prescriber or a dispenser shall secure prior authorization from the department or its designee as a condition of payment for those drugs subject to prior authorization. 3. A prescriber or a dispenser shall provide to the department or its designee in the format required by the department the data necessary for the department or its designee to make a decision regarding prior authorization. The department shall deny a claim for coverage of a drug requiring prior authorization if the prescription was dispensed prior to authorization or if the required information regarding the prior authorization is not provided by the prescriber or the dispenser. 4. A prescriber or dispenser shall submit a request for prior authorization to the department or its designee by telephone, facsimile, electronic mail, or in any other format designated by the department. The department or its designee shall respond to a prior authorization request within twenty-four hours of receipt of a complete request that contains all of the data necessary for the department to make a determination. 5. Emergency supply. a. If a recipient needs a drug before a prescriber or dispenser can secure prior authorization from the department, the department shall provide coverage of the lesser of a five-day supply of a drug or the amount prescribed if it is not feasible to dispense a five-day supply because the drug is packaged in such a way that it is not intended to be further divided. b. The department may not provide further coverage of the drug beyond the five-day supply unless the prescriber or dispenser first secures prior authorization from the department. 6. The department shall authorize the provision of a drug subject to prior authorization if: a. Other drugs not requiring prior authorization have not been effective or with reasonable certainty are not expected to be effective in treating the recipient's condition; b. Other drugs not requiring prior authorization cause or are reasonably expected to cause adverse or harmful reactions to the health of the recipient; or c. The drug is prescribed for a medically accepted use supported by a compendium or by approved product labeling unless there is a therapeutically equivalent drug that is available without prior authorization. 27 7. If a recipient is receiving coverage of a drug that is later subject to prior authorization requirements, the department shall continue to provide coverage of that drug until the prescriber reevaluates the recipient. The department shall provide a form by which a prescriber may inform the department of a drug that a recipient shall continue to receive beyond the prescription reevaluation period regardless of whether such drug requires prior authorization. The form must contain the following information: a. The requested drug and its indication; b. An explanation as to why the drug is medically necessary; and c. The signature of the prescriber confirming that the prescriber has considered generic or other alternatives and has determined that continuing current therapy is in the best interest for successful medical management of the recipient. 8. If a recipient under the age of twenty-two has a medication regimen that contains five or more concurrent prescriptions for antipsychotics, antidepressants, anticonvulsants, benzodiazepines, mood stabilizers, sedative, hypnotics, or medications used for the treatment of attention deficit hyperactivity disorder, the department shall require that the prescribers certify annually the medical necessity of each medication in the regimen. The department may apply the certification process to other individuals at the discretion of the department. 9. The department may require prior authorization for any medication that is a line extension drug in any of the excluded medication classes under subsection 3 of North Dakota Century Code section 50-24.6-04 if the line extension drug's net cost is higher than the original medication due to federal drug rebate offset differences. 10. The department may require prior authorization for any medication that is a drug in any of the excluded medication classes under subsection 3 of North Dakota Century Code section 50-24.6-04 if a manufacturer of a drug in that class excludes the department from supplemental rebate offers or value-based purchasing agreement offers due to the existence of the prior authorization exclusion in subdivision a of subsection 3 of North Dakota Century Code section 50-24.6-04. History: Effective September 1, 2003; amended effective July 26, 2004; July 1, 2006; October 1, 2012; April 1, 2018; April 1, 2020; January 1, 2022; January 1, 2024; January 1, 2026. General Authority: NDCC 50-24.6-04, 50-24.6-10 Law Implemented: NDCC 50-24.6; 42 USC 1396r-8