Prior Authorizations

About Prior Authorizations

Prior Authorization
Some medications require prior approval before to being paid by HPSJ. The prior authorization program is in place to ensure appropriate, effective, and efficient use of medications based on the most current clinical evidence. Prior authorization requests are reviewed by HPSJ Clinical Pharmacy staff. All Prior Authorization requests are reviewed and a determination is made within 1 business day. The medications requiring prior authorization and the specific requirements are subject to change (as often as quarterly).

Generic Substitution
Whenever an FDA-approved bioequivalent generic drug is available and there are no medical contraindications to patient use of the generic drug HPSJ substitutes the generic drug. A prescriber may, for medical reasons, request that a prescription be dispensed as written (DAW), subject to review and approval by HPSJ. In general, if a patient is “intolerant” to a product from one manufacturer, products from other manufacturers should be tried. If the requesting provider states that it is medically necessary to take the brand medication due to an adverse events or side effect experienced with all generic forms of the medication by all generic manufacturers, the requesting provider must provide evidence that a MEDWATCH form has been completed and submitted to the FDA documenting the adverse event experienced with the generic medication but not with the brand name medication.

Restrictions and Limits
In collaboration with the HPSJ P&T Advisory Committee, HPSJ may place limits or restrictions on medications to improve patient safety and to prevent overuse of medications. Types of Restrictions may include 1 or more of the following:

Certain predetermined criteria must be met for coverage to be approved
The member must try and fail one or more therapeutic alternatives before approval
Only a certain number of units (e.g., tablets, capsules, milliliters) may be approved
The member may only fill the medication a certain number of times within a specified time period
The medication may only be filled for one biological gender (male/female)
The medication is restricted to members who are within a pre-defined age range
The medication may only be prescribed by licensed specialists (e.g., Neurologists)
The medication is restricted to a specialty pharmacy and may only be dispensed from that pharmacy.

Non-Formulary Medication Exception Requests
Any medication not on the HPSJ Formulary requires prior authorization to be covered by HPSJ and will go through the standard prior authorization process. Information needed to process a formulary exception request includes

  • All information requested on the pharmacy prior authorization request form
  • Clinical justification why formulary alternatives cannot be used
  • Documentation of inadequate therapeutic response to three different formulary alternatives

Formulary Exception Request Review Criteria
Exception request are reviewed against the following criteria:

    • Clinical documentation of three different formulary alternatives previously tried without positive therapeutic response
    • The member has/develops contraindication or intolerance to all formulary alternatives
    • No formulary alternatives exist to treat the member’s condition.
    • The member has been established on and responded to the non-formulary medication immediately prior to enrollment
  • Continuation of a non-formulary medication based on a sample given to the member will not be accepted as a valid reason for approval.
  • Medications that are prescribed for a limited timeframe then discontinued are not eligible for continuation based on the above criteria.


How to submit prior authorization requests:
In order to expeditiously approve medically necessary medications for which prior authorization is required, please complete all steps below:

Submission of Pharmacy Claims
All claims must be billed to the contracted PBA (ProCare Rx).
claims


 

Appeals
Appeals of decisions can be made by sending additional information regarding the request while referencing the original request, and indicating that this request is an appeal to the pharmacy department directly using the standard PA form or directly through the grievance/appeals team.

Cash-Payment
Under no circumstances may a Medi-Cal recipient (including HPSJ Members) be billed or charged directly for after-hours or delivery services (Title 22). Pharmacies are not permitted to fill non-formulary prescriptions for cash payment in lieu of the PA process.

Epocrates®
HPSJ utilizes an online service for providers to have easy access to the HPSJ Formulary in clinical practice through Epocrates ® [www.epocrates.com].

Coordination of Benefits (COB)
HPSJ Members may have prescription coverage through other payment sources. If Member has other primary health insurance coverage, pharmacy providers must submit claims to the other payment source first. The State law requires the Medi-Cal Members and Providers to notify the Department of Health Services if they believe a member has “other health coverage”.
HPSJ is the payer of last resort for coordination of benefits claims. HPSJ is responsible for co-insurance, and co-payments only after all prior authorization processes through the primary payer have been exhausted. All COB claims must be submitted electronically to the PBA.

Per Title 22 of the California Code of Regulations, Providers may not refuse treatment of HPSJ Members because 1) HPSJ Member has other health care coverage 2) the Provider may be required to bill HPSJ as a secondary (electronically or manually).

PHARMACY INSTRUCTIONS FOR COB BILLING: To bill online through the PBA: Bill primary coverage first and bill copay as e-COB using the member ID (200____) as member ID# and 01 as person code, enter “08” (billing for copay) in the Other Coverage Code field.

Therapeutic Interchange Protocols
HPSJ uses Therapeutic Interchange to promote rational pharmaceutical therapy when evidence suggests that outcomes can be improved by substituting a drug that is therapeutically equivalent but chemically different from the prescribed drug. Improved outcomes include, but are not limited to, enhanced compliance, superior side-effect or risk profile, clinically superior results, and equivalent clinical results at reduced cost. Therapeutic Interchange protocols are developed in collaboration with the HPSJ P&T Advisory Committee and are based off of the most current clinical evidence.

Therapeutic Interchange protocols are never automatic. That is, a dispensing provider may not substitute an alternate, therapeutically equivalent, drug for a prescribed drug without the knowledge and authorization of the prescribing practitioner.

  • When a Therapeutic Interchange opportunity is identified at the point-of dispensing, the dispensing pharmacy receives relevant clinical information about the proposed Therapeutic Interchange and a message asking him/her to discuss the potential Therapeutic Interchange with the prescribing practitioner.
  • If the prescribing practitioner approves the Therapeutic Interchange, the new prescription is reviewed and validated by the dispensing practitioner before it is filled.
  • The dispensing pharmacy notifies the member of the Therapeutic Interchange.
  • If the prescribing practitioner does not approve the proposed Therapeutic Interchange, the member’s file is marked to prevent future intervention on that drug.
  • Therapeutic Interchange is voluntary on the part of the member and the prescribing practitioner.

Posted on July 17th, 2015 and last modified on November 2nd, 2017.