CHAPTER 113
S.P. 493 - L.D. 1404
Resolve, To Increase the Quality of Care and Reduce Administrative Burdens in the Pharmacy Prior Approval Process
Sec. 1. Preferred drug lists and prior authorization. Resolved: That the Department of Health and Human Services shall take the following actions to promote the quality of care and reduce administrative burdens in the pharmacy prior approval process.
1. The department shall specify on the preferred drug list and on the prior authorization form the number, titration if required and classes of preferred drugs that must be determined to be clinically inappropriate or ineffective before the department will permit the use of a nonpreferred drug.
2. In the next changes to the MaineCare Benefits Manual, but no later than January 15, 2006, the department shall adopt a provision to articulate the current standards for off-label drug use of prescription drugs for children.
3. The department shall change the prior authorization forms to provide examples of clinical conditions and functional limitations that could support a waiver of prior authorization.
4. By January 2006, the department shall amend its rules regarding prior authorization to include the criteria for approving special exception overrides. The department shall arrange to modify the message screen to include a reminder that overrides may be available. The message format must comply with National Council for Prescription Drug Programs standards.
5. By October 1, 2005, the department shall minimize the burden on providers of submitting duplicative medical records on behalf of a MaineCare member. In order to reduce the submission of duplicate information, the department shall work to provide notice to providers of the types of documentation required and to create a prior authorization file for each member.
6. The department shall provide prompt notice of changes to the preferred drug list through posting on its website, its group electronic mailings regarding pharmacy issues and notices to provider organizations.
7. The department shall arrange to allow submission of the prior authorization form and other required documentation as an e-mail attachment when such submissions are feasible.
8. By January 15, 2006, the department shall amend its rules regarding the drug utilization review committee under the MaineCare Benefits Manual, chapter II, section 80.01-13 to establish conflict-of-interest standards for members of the committee.
9. The department shall consult with the MaineCare Advisory Committee on the design of future studies related to pharmacy prior authorization, including a survey of MaineCare members. The department shall report to the Joint Standing Committee on Health and Human Services by February 1, 2006 on its progress in implementing this subsection.
Effective September 17, 2005.
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