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children through an approval process that is determined in | accordance with the requirements of 42 United States Code, | Section 1396(r)(5). |
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| | 2.__Prior authorization.__In the adoption of any prior | authorization process for pharmacy benefits, the provisions of | this subsection apply. |
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| A.__The department shall adopt rules providing clinical | exemptions from the prior authorization process for at least | the following groups of persons: |
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| (1) Members who are unable to adequately communicate | their health condition as a result of dementia or other | cognitive or physical impairment; |
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| (2)__Members who reside in health care or residential | care facilities; |
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| (3)__Members who have acute psychiatric conditions that | have been stabilized on a nonpreferred drug and who, in | the judgment of the treating health care provider, | would suffer an adverse health effect as a result of | changing that drug; |
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| (4)__Members whose medical condition has been | stabilized on a nonpreferred drug during | hospitalization or who have been prescribed a | nonpreferred drug upon discharge so that they may | continue to receive the drug following hospitalization | for a transition period of at least 90 days; |
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| (5)__Members for whom the abrupt termination of a | certain prescribed drug may cause serious harm; and |
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| (6)__Members who are frail or medically vulnerable, | including those diagnosed with HIV or AIDS, for whom | exclusion from prior authorization is clinically | appropriate. |
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| B.__The department shall adopt rules that provide for | dispensing drugs on an emergency basis. |
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| (1)__The rules must apply if a prescribing provider | fails to submit a completed application for prior | authorization or to attach the required documentation. |
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| (2)__The rules must authorize the pharmacy to dispense, in | accordance with applicable licensing standards and |
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