PDFWAC 182-530-3000

When the medicaid agency requires authorization.

Covered drugs, devices, or drug-related supplies require authorization for reimbursement when:
(1) The medicaid agency's pharmacists or medical consultants:
(a) Have determined that authorization for the drug, device, or drug-related supply is required, as described in WAC 182-530-3100; or
(b) Have not yet reviewed the drug, device, or drug-related supply as described in WAC 182-530-3100.
(2) The drug, device, or drug-related supply is in a therapeutic drug class on the Washington preferred drug list and the product is one of the following:
(a) Nonpreferred as described in WAC 182-530-4100; and
(i) The prescriber is a nonendorsing practitioner; or
(ii) The drug is designated as exempt from the therapeutic interchange program per WAC 182-530-4100(6) or 182-530-4150 (2)(a);
(b) Preferred for a special population or specific indication and has been prescribed by a nonendorsing practitioner under conditions for which the drug, device, or drug-related supply is not preferred; or
(c) Determined to require authorization for safety.
(3) The agency is promoting safety, efficacy, and effectiveness of drug therapy, or the agency identifies clients or groups of clients who would benefit from further clinical review.
(4) The agency designates the prescriber(s) as requiring authorization because the prescriber(s) is under agency review or is sanctioned for substandard quality of care.
(5) Utilization data indicate there are health and safety concerns or the potential for misuse and abuse. Examples of utilization concerns include:
(a) Multiple prescriptions filled for the same drug in the same calendar month;
(b) Prescriptions filled earlier than necessary for optimal therapeutic response;
(c) Therapeutic duplication;
(d) Therapeutic contraindication;
(e) Excessive dosing, excessive duration of therapy, or subtherapeutic dosing as determined by FDA labeling or the compendia of drug information; and
(f) Number of prescriptions filled per month in total or by therapeutic drug class.
(6) The pharmacy requests reimbursement in excess of the maximum allowable cost and the drug has been prescribed with instructions to dispense as written.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-07-001, § 182-530-3000, filed 3/1/17, effective 4/1/17; WSR 16-01-046, § 182-530-3000, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-3000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. WSR 08-21-107, § 388-530-3000, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-3000, filed 9/26/07, effective 11/1/07.]