(Prepared by the Texas Medical Association)
Updated: Feb. 16, 2004
[ Prior Authorization Process | 72-Hour Emergency Supply | Quality of Care | Addition of Other Drug Classes to the PDL | Physician/Stakeholder Education | Miscellaneous | Volume II: Questions About Preferred Drug List ]
Prior Authorization Process
Q. Who do I call to obtain prior authorization?
A. The state has contracted with Heritage Information Systems to conduct prior authorization for nonpreferred drugs. To contact the call center, dial 1-877-PA-Texas.
Physicians and other licensed prescribers or their staff may obtain prior authorization. Information needed for a timely decision:
Recipient-specific information:
Texas Medicaid assigned recipient ID number
Recipient Name
Recipient Date of Birth
Reason for requesting override for a nonpreferred drug
Prescriber-specific information:
Texas Medicaid assigned provider ID number
(5-character Texas license number)
Physician Name (or Delegating Physician Name)
Claim-specific information:
Requested drug and strength
Days supply
Number of refills
Requests submitted with missing information will not be assessed until that information can be provided.
Q. Once prior authorization is obtained, how long is the approval valid? Will there be exceptions to the timeframe for certain patient populations or drug classes?
A. Prior authorization is valid for one year. There are no deviations from this timeframe for certain patient populations or drug classes.
Q. The Jan. 20 letter to providers states that only the “prescribing” physician or his or her staff can request prior authorization. Can an on-call physician obtain prior authorization when the prescribing physician is not available?
A. Yes. An on-call physician may also request prior authorization.
Q. Will the call center notify the patient or pharmacy when prior authorization is obtained?
A. No, patients are not directly notified. At the time a prescription is written, physicians should call 1-877-PA-Texas to obtain prior authorization. In most cases, a decision will be made at the time of the call (if all required information is provided). Prior authorization is noted in the Medicaid claims system, which pharmacists can access when submitting a claim. If prior authorization is not obtained at that time, or prior authorization is sought at the pharmacy counter, the call center only notifies the physician directly.
Q. If prior authorization is denied, what is the appeal process for physicians and patients? Can physicians appeal the decision to the HHSC Medicaid medical director and/or a physician in his or her specialty?
A. If the call center denies a prior authorization request, the prescriber may submit a Request for Reconsideration via mail. If the Request for Reconsideration is denied, patients may appeal through the Medicaid fair hearing process.
Q. The written material provided by HHSC does not make it clear that Advanced Practice Nurses or Physician Assistants can obtain prior authorization directly. Many APNs and PAs practice under physician protocol and supervision at a remote location. The information should make it clear that these prescribers can obtain prior authorization.
A. APNs and PAs can obtain prior authorization directly.
Q. If a patient receives a prescription in the emergency room for a nonpreferred drug, and leaves the emergency department to fill the prescription at a community pharmacy, who would the patient contact to obtain prior authorization if such authorization is not obtained at the time of the emergency visit? It is likely the patient will not be able to contact the emergency physician directly without returning to the emergency department.
A. In this situation, the pharmacist or patient could contact the emergency department, the patient could return to the emergency department, or the patient could follow up with his or her primary care physician or provider. HHSC will continue to work to minimize the disruption to patients, physicians, and pharmacists in this type of scenario.
Q. Will Heritage Information Systems implement an on-line system for obtaining prior authorization?
A. An online system for obtaining prior authorization is not yet available, but Heritage Information Systems intends to launch a system later this year.
Q. Can physicians or other prescribers submit requests for prior authorization in batches? For example, if a physician has a lot of patients who have contraindications for a preferred agent, can the physician fax Heritage a list of those patients with supporting information so that prior authorization can be done for all of them at one time?
A. Prior authorization requests may not be submitted via fax, and must be done for each patient on an individual basis. HHSC encourages prescribers to switch patients to a preferred product when possible. If a prescriber needs to request multiple prior authorizations, the call center is open 7:30 am–6:30 pm CST Monday through Friday.
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72-Hour Emergency Supply
Q. In emergency situations, the pharmacist may dispense a 72-hour supply of a nonpreferred drug pending receipt of prior authorization. How will the state define “emergency?” For example, instructions state that at the Point of Sale, the patient should contact his or her physician to obtain prior authorization for a nonpreferred drug. If the patient calls the physician during normal business hours (9 am to 5 pm), but his or her physician is not available (e.g., office closed, physician in surgery, etc.), can the pharmacy dispense the 72-hour supply anyway?
A. The definition of an emergency will be at the discretion of the pharmacist. HHSC will monitor pharmacists’ utilization of this exception to minimize its abuse.
Q. If at the end of 72-hours prior authorization still has not been obtained, may the pharmacist dispense another 72-hour emergency supply?
A. Yes. The prior authorization vendor and HHSC will monitor and work with the pharmacist and physician to assure timely prior authorization of nonpreferred drugs.
Q. Does the pharmacist have to call HHSC and/or the vendor to obtain authorization for dispensing a 72-hour emergency supply?
A. No
Q. The Jan. 20 letter to providers does not mention the availability of a 72-hour emergency supply. Are pharmacists and patients being alerted to this option through other means?
A. Yes.
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Quality of Care
Q. Will HHSC (or its contractor) make available the clinical and safety information used by Provider Synergies and the P&T Committee to develop the PDL (we understand cost information is proprietary)? Our research indicates that some states, like Oregon, make this information available to the public via their Medicaid Web site It would be helpful to have this information prior to hearings on each drug class so that any additional, relevant clinical information can be shared with the P&T Committee and HHSC prior to a decision being rendered.
A. HHSC is considering posting summaries of the clinical monographs and other background information on its Web site. A decision is not yet final.
Q. If the P&T Committee recommends inclusion of a drug on the preferred list based on evidence that the drug is clinically superior and safe, but the pharmaceutical manufacturer has not agreed to a supplemental rebate or other financial arrangement with the state, will that drug still be excluded from the preferred list?
A. Yes.
Q. If a drug is excluded because a supplemental rebate was not obtained, will HHSC publish which drugs fall into this category?
A. No.
Q. If a drug is excluded from the preferred drug list, but additional clinical evidence arises that suggests the drug should be considered preferred, what is the mechanism for physicians to request the P&T Committee and/or HHSC to reconsider its decision?
A. HHSC is developing a process and additional guidance will be forthcoming.
Q. In situations where a nonpreferred drug is requested, will Heritage Information Systems enforce a “fail first” policy when a patient has not previously used a preferred agent?
A. Heritage will consider the following criteria when determining whether to approve a nonpreferred drug: previous failure on a preferred agent, allergy, or clinical contraindication.
Q. Who is developing the clinical criteria for approving nonpreferred drugs?
A. The criteria will be developed with input from the state’s Drug Utilization Review Board, composed of physicians and pharmacists, the Pharmaceutical and Therapeutics Committee, Heritage Information Systems, and HHSC.
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Addition of Other Drug Classes to the PDL
Q. Has HHSC established a schedule for implementation of the PDL/prior authorization process for the remaining drug classes? For example, the P&T committee met in January to consider 14 additional drug classes. When will the PDL/PA process affect those drugs?
A. A schedule is under development. Physicians and pharmacists will be given at least 30 days notice prior to placing drugs on the preferred or nonpreferred lists.
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Physician/Stakeholder Education
Q. Besides the Jan. 20 letter to physicians/providers, what steps has HHSC taken to educate physicians about initiation of the PDL and prior authorization process?
A. HHSC mailed a letter the week of Jan. 20 to some 15,000 high-volume Medicaid physicians to provide information about the PDL and prior authorization process and to identify their patients on nonpreferred drugs. In addition, HHSC mailed a copy of the PDL and prior authorization process to over 25,000 other physicians. HHSC published an article in the Medicaid Jan/Feb Medicaid Bulletin and has posted information on its Web site.
Q. What steps have been taken to educate patients, pharmacists and other stakeholders about the process?
A. Pharmacists were notified through letters and postings on the HHSC Web site. HHSC is not notifying patients directly because of concerns about unduly alarming patients about potential changes to their medications.
Q. What additional steps, if any, have been taken to educate high volume prescribers and pharmacists about the PDL and prior authorization process?
A. The contractor managing the prior authorization process, Heritage Information Systems, is making calls directly to high volume prescribers to alert them to the PDL and prior authorization process. TMA is working with HHSC to facilitate these calls.
Q. As the PDL evolves, how will HHSC communicate changes to physicians, pharmacists, and patients?
A. HHSC Web site, Medicaid Bulletin, communication with provider associations, and targeted letters to prescribers.
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Miscellaneous
Q. Who does a physician contact to inform HHSC and/or the vendor that a patient(s) listed as being in the physician’s care is not a patient of record?
A. Physicians should call Heritage Information Systems at 1-877-PA-Texas. Physicians should note that they may not recognize all patients listed in their care because a patient may have been seen in another setting (e.g., a community clinic) or the patient may be under the care of the physician’s advanced practice nurse or physician assistant.
Q. Can physicians bill for services if a patient must be reexamined prior to switching the patient from a nonpreferred agent to a preferred agent?
A. Yes. Physicians must be able to document a reasonable medical justification for the visit.
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Volume II: Questions About Preferred Drug List
(submitted by the Texas Medical Association)
Q: HHSC has stated Heritage Information Systems will not accept “block” prior authorizations requests from physicians who have multiple patients with medical justification to use a nonpreferred agent. If a physician has multiple patients for whom prior authorization is needed, will the physician have to make a separate phone call for each individual patient or can the physician make one phone call to request prior authorization for each of patient in need of a nonpreferred drug?
A. The physician can make one phone call to request prior authorizations for multiple patients. If physicians have large numbers of patients who will require prior authorization, HHSC encourages physicians or their representative to contact the call center before February 23.
Q. What are the professional requirements for the call center staff?
A. The call center staff includes certified pharmacy technicians and pharmacists.
Q. What is the timeframe for the DUR Board and the P&T to develop the clinical criteria for approval of nonpreferred drugs? Will the criteria be made publicly available?
A. The current criteria for approval of nonpreferred drugs are listed in the final column of the Preferred Drug List that is posted on the HHSC Web site. HHSC will be working with the DUR Board and P&T Committee once the PDL is implemented to refine the prior authorization criteria by drug class. The criteria will be made publicly available.
Q. If a manufacturer declines to give a supplemental rebate for a drug approved by the P&T committee, can the manufacturer subsequently agree to a rebate and have its product(s) added to the PDL without additional review?
A. In order for a drug to be considered for placement on the PDL, the manufacturer must offer a supplemental rebate. If a manufacturer does not choose to offer a supplemental rebate in time for P&T Committee consideration, but later offers a rebate, then there is no guarantee that it will be placed on the PDL without further review.
Q. To monitor the efficacy of the prior authorization process, will HHSC/Heritage collect and publish statistics on:
-the number of requests for nonpreferred drugs by class?
-number of and reason for approved requests?
-number of and reasons for denied requests?
-the number of requested appeals requested and their outcome?
A. HHSC will collect and analyze statistics on the prior authorization process. Each year HHSC is required to report to the Legislature and the Governor statistical information on the number of approvals granted or denied. HHSC also may publish this information more frequently.
Q. If a request for a nonpreferred drug is denied, will the physician and patient be given the reason for the denial?
A. If a physician request is denied at the call center, the physician or staff representative will know at the time of the call that the patient doesn’t meet the prior authorization criteria and will be informed of the option to mail in a Reconsideration Request form. If the Reconsideration Request is denied, both the physician and patient will receive a letter explaining the denial.
Q. The appeal process states that only a patient can request an appeal for a denied nonpreferred drug. However, it is the physician who will be able to articulate the clinical basis for an appeal. Will HHSC consider allowing the physician to appeal on behalf of the patient (which is allowed for commercial managed care plans).
A. If a prior authorization request is denied during the phone call , the first-line appeal, or Reconsideration Request, is made by the physician in order to allow him/her to articulate the clinical reason why the patient needs the nonpreferred drug. If the Reconsideration Request is denied, then the patient will be notified of their right to appeal through the Medicaid Fair Hearing process.
Q. There are three justifications for approving a nonpreferred drug: previous failure on a preferred agent, clinical contraindication, or allergy. Why, then, can’t the prescriber write the reason for a prescribing a nonpreferred drug directly onto the prescription? This would save a phone call to Heritage and simplify the prior authorization process considerably. HHSC could still audit the prescriptions and/or prescriber to assure prescriptions for nonpreferred drugs are medically necessary.
A. HB 2292 requires that the prior authorization be obtained by the prescribing physician or other prescriber. As is the standard with prior authorization programs, HHSC is requiring that prior authorization be obtained via phone call unless we have data to show that the client meets the prior authorization criteria. HHSC, with the help of the DUR Board and P&T Committee, will be further refining the prior authorization criteria by drug class.
Q. In the Jan. 20 letter to physicians, physicians were given a list of patients currently taking a nonpreferred drug. The list, however, did not indicate which drug the patient is currently taking or provide a list of the preferred agents. If a patient were prescribed a drug at the ER or another setting outside the physician’s office (e.g., a community clinic), a chart may not be available to determine what drug(s) the patient is currently taking. Administratively, it would simplify the PA process for physicians if the notice indicated a) what drug the patient already is taking and b) listed the drugs classified as preferred.
A. HHSC will coordinate with Heritage Information Systems to see if these items may be added to the next set of letters. A copy of the PDL accompanies the letter.
Q. How did HHSC determine which complex, life-threatening illnesses would be excluded from the PDL/PA process pending study of the impact of a prior authorization on treatment of those illnesses? For example, questions are being asked about why diabetes, severe mental illnesses, and some cardiovascular diseases were not included in the study.
A. HHSC medical staff determined that the following illnesses meet all three of the criteria required for the study: HIVS/AIDS, cancer and hemophilia.
Q. When will HHSC release the study findings regarding the impact of prior authorization on chronic, life threatening illnesses?
A. HHSC is reviewing a draft of the study now, and will release it once the study is finalized and the review is complete.
Q. What is the process to coordinate the PDL development process with the Texas Diabetes Council and the Texas Cardiovascular Council, respectively?
A. At this time, there is no formal process to coordinate with the Texas Diabetes Council and the Texas Cardiovascular Council. The Texas Diabetes Council did submit comments that the P&T Committee considered at its January meeting.
Q. Concern has been raised about the classification of narcotic agents since the drug class includes both narcotic and non-narcotic agents (Schedule III) and a few single-agent (Schedule II) drugs. The questions then, is what happens if a physician prescribes "oxycodone" which is on the "pending-no PA required" list, and specify that the agent be long-acting, and in a tablet-dose of 40 mgm? Oxycodone requires no PA, but the only agent that meets the other two specs is Oxycontin (a "nonpreferred" agent). Since I prescribed it generically, can the pharmacist fill it with the only medicine available that meets criteria?
A. While there are generic oxycodone products available in the Vendor Drug formulary without prior approval, there are no generic forms of the long acting oxycodone. If a physician writes a prescription for oxycodone LA or SA the only product which could be dispensed under State Board of Pharmacy rules would be the name brand product Oxycontin which would require prior authorization.
Q. The "Angiotensin receptor blocker" therapeutic class has a series of COMBINATION agents containing a diuretic, as well as non-combination drugs containing only the ARB in both the preferred and nonpreferred lists. The P&T committee was careful to properly label the ACE inhibitor/CCB therapeutic class as "combination drugs." This failure to respect the combinations vs. the single agents by properly separating them into their own categories carries over into the antihistamines and the beta agonist bronchodilators, which is certain to create confusion. Will HHSC consider changing the classifications in the future, such as not considering schedule II through schedule IV agents as being in the same "class," and NOT considering combination agents as in the same class as single entity agents? Another option would be to classify the drugs according to therapeutic intent, such as "drugs for hypertension" and "drugs for asthma."
A. We have attempted to group drugs into therapeutic classes in way that facilitates the PDL development process and is understandable to physicians and pharmacies. The therapeutic classes that Texas is using have been used in several other states without any problem. As we develop and implement the PDL, there is some education and familiarization that will occur during the early phases.
We do not separate ARB and ARB/diuretic combinations because we want to have the same ARBs both with and without the diuretic on the PDL. The same is true for the antihistamine and antihistamine/decongestant combinations. The beta agonist bronchodilator/steroid combination product is the only one of its type; therefore, if we separated it as a combination agent it would be in a class by itself. As more unique combination products arrive on the market (CCB/statin, atypical antipsychotic/SSRI, etc.), we believe it would be more confusing to have numerous one-drug classes.
As far as the narcotic analgesics, we do not perceive each FDA schedule (II, III, and IV) as being its own therapeutic drug class. Some prescribers may not know which drugs are in which class, especially Classes III and IV, so breaking this class of drugs down into several classes may result in confusion.
It is not always possible to classify drugs according to their FDA indications because most drugs have more than one indication and drugs are often used for off-label indications. For instance, would Foradil and Serevent be in the "Drugs used for asthma" or "Drugs used for COPD" class?
HHSC may be able to adapt the PDL document to respond to some of your comments by:
- Changing the names of some of the classes that have combination products. For example, the Angiotensin Receptor Blockers class could be renamed Angiotensin Receptor Blockers and Angiotensin Receptor Blocker/Diuretic Combinations.
- Cross-referencing combination products that have components from two classes. For example, Advair could be included in the Corticosteroids, Inhaled and Beta Agonist Bronchodilator classes.
- For the Narcotic Analgesics, breaking down the products by FDA Class or, probably more appropriately, by relative potency.
Q. What steps have been taken to educate the Medicaid managed care plans about implementation of the PDL? TMA has received several calls from physician offices confused about whether Medicaid managed care patients are subject to the PDL and prior authorization process. When the physicians contacted their local plan representatives, the representatives were unable to confirm that Medicaid managed care patients are indeed subject to the PDL.
A. Dr. Hellerstedt met with the Medicaid Managed Care Medical Directors on Jan. 22 and provided some information and led a discussion on PDL. HHSC staff discussed the PDL with Medicaid managed care representatives last week, and confirmed that Medicaid managed care patients will be subject to the PDL. HHSC sent the STAR plans PDL/PA program information early this week.
Q. When will HHSC make a final decision regarding which behavioral health drugs will be included on the preferred drug list?
A. HHSC's PDL decision on antidepressants currently is posted on the HHSC Web site. HHSC has not set a specific date by which it will make a decision for atypical antipsychotics.
Q. The Pharmaceutical and Therapeutics Committee recommended Prozac be nonpreferred. Will an exception be made for adolescents? Prozac is one of the few antidepressants with FDA indication for treating adolescent depression.
A. While brand name Prozac will require prior authorization, the generic equivalent will be available without prior authorization.
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Last Published: 3/31/2005
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