Section 471-16-009 - LIMITATIONS AND REQUIREMENTS FOR CERTAIN DRUGS009.01PRIOR AUTHORIZATION. The Department requires authorization be granted prior to payment for certain drugs. Should a practitioner dispense a prescription prior to the actual authorization, he or she takes a business risk payment for the prescription can be denied. 009.01(A)PRIOR AUTHORIZATION RESPONSE. The Nebraska Point of Purchase contractor or the Department will respond to any request for prior authorization within 24 hours of receipt of the request.009.01(B)APPROVAL DECISION. The Nebraska Point of Purchase contractor or the Department will notify the provider prescribing the drug or the pharmacy dispensing the drug if the authorization has been granted, the eligible dates of the authorization, and the identification of the provider who requested the authorization. The prior authorization is given for the drug, the client, and the prior authorization dates.009.01(C)DENIAL DECISION. The Nebraska Point of Purchase contractor or the Department will notify the provider prescribing the drug or the pharmacy dispensing the drug if coverage is denied.009.01(D)EMERGENCY DECISION. The Nebraska Point of Purchase contractor or the Department will authorize dispensing up to a 72-hour supply of a covered outpatient prescribed medication for cases meeting the definition of a medical emergency as outlined in chapter two of this title.009.01(E)UNKNOWN DECISION. If the provider prescribing the drug or the pharmacy dispensing the drug has not received an authorization from the Nebraska Point of Purchase contractor or the Department, payment may be denied.009.01(F)VERIFYING STATUS OF REQUESTS. The pharmacy can verify the status of prior authorization requests for prescriptions by submitting a claim via the Nebraska Point of Purchase System, if the prior authorization request has not been approved, the pharmacy may contact the Nebraska Point of Purchase contractor or the Department for prior authorization.009.02PRODUCTS REQUIRING PRIOR APPROVAL. Identifiable products requiring approval prior to payment are designated as such on the Nebraska Point of Purchase System or on the Nebraska Medicaid Pharmacy Program website. Reasons for prior authorization include:(A) Product Based Controls. Prior authorizations falling under this category are products where there are medically appropriate alternative treatments which are more cost-effective for the Department:(B) Utilization Controls. Prior authorizations failing under this category generally apply to the quantity of medication or duration of therapy approved: and(C) Scope Controls. Scope controls ensure a drug is used for an approved or medically accepted indication, is clinically appropriate, medically necessary, and cost-effective; (i) Medications which have been approved by the Federal Food and Drug Administration for multiple indications may be subject to a scope-based prior authorization when at least one of the approved indications places the drug in a therapeutic category or treatment class for which a prior authorization is required:(ii) Prior authorization may be required to assure compliance with Federal Food and Drug Administration approved and medically accepted indications, dosage, duration of therapy, quantity, or other appropriate use criteria including pharmacoeconomic consideration; or(iii) Prior authorization may be required for certain non-standard dosage forms of medications when the drug is available in standard dosage forms.009.03PREFERRED DRUG LIST.009.03(A)PREFERRED DRUG LIST. The Medicaid Prescription Drug Act of 2008 requires the Department to establish and maintain a Preferred Drug List for the Medicaid program with the aid of the Pharmaceutical and Therapeutics Committee. Individual drugs will be designated as preferred or non-preferred within therapeutic classes of prescribed drugs reviewed by the Pharmaceutical and Therapeutics Committee. Drugs designated as preferred drugs can be prescribed for Medicaid clients without prior authorization from the Department: however some Preferred Drugs may have clinical claim limits to ensure appropriate use. The Preferred Drug List and other related activities are not construed to replace, prohibit, or limit other lawful activities of the Department not specifically permitted or required by the Act. Drugs classified as Preferred Drugs will be eligible for supplemental rebates as described under the provisions of this title. The Department will maintain an updated Preferred Drug List in electronic format and will make the list available to the public from the Nebraska Medicaid Pharmacy Program website. Drugs and classes of drugs included on the Preferred Drug List will be reviewed annually. Changes will be communicated to providers at least 30 days prior to implementation. 009.03(B)DRUGS INCLUDED ON THE PREFERRED DRUG LIST. The Department will include on the Preferred Drug List prescribed drugs which are found to be therapeutically equivalent to or superior to other drugs within a therapeutic class, and the net cost of the drugs are equal to or less than other drugs within a therapeutic class after consideration of applicable rebates or discounts negotiated by the Department or its designated contractor. All classes of medications are considered for inclusion on the preferred drug list (PPL) except the antidepressants, antipsychotics or anticonvulsant medications.009.03(C)NON-PREFERRED DRUGS. Medications designated as non-preferred on the Preferred Drug List will be subject to prior authorization. The Pharmaceutical and Therapeutics Committee will develop criteria for use of medications with non-preferred status. A health care provider may prescribe a drug designated as non-preferred on the Preferred Drug List to a Medicaid client without prior authorization by the Department if the provider certifies: (i) The client is achieving therapeutic success with a course of medication for Human Immunodeficiency Virus, Multiple Sclerosis, cancer, or immunosuppressant therapy; or(ii) The client has experienced a prior therapeutic failure with a medication designated as a Preferred Drug.471 Neb. Admin. Code, ch. 16, § 009
Adopted effective 12/26/2021