Medications

1
Medications

• Prior Authorization

2
Medications Requiring PA
3
Medications - continued
4
Synagis

• Used in preventing severe lower respiratory
  tract infections caused by respiratory syncytial
  virus (RSV) in high risk infants, children
  younger than 24 months with chronic lung disease,
  and certain preterm infants.

5
Risperdal Consta

• Indicated for the treatment of Schizophrenia
  (ICD-9 codes 295 295.9). Authorization is based
  on specific criteria including the patients
  failure to respond to oral antipsychotic
  medications or non-compliance with oral
  antipsychotic medications.

6
Lucentis

• Indicated for the treatment of Age Related
  Macular Degeneration (AMD) ICD-9 diagnosis
  362.52.

7
Elaprase

• Indicated for the treatment of Hunter Syndrome
  or Mucopolysaccharidosis II ICD-9 diagnosis
  277.5 and ICD-10 diagnosis E76.1.

8
Orencia

• Used to treat moderate to severe active
  rheumatoid arthritis in adults (RA - ICD-9
  diagnosis 714.0).

9
Tysabri

• Indicated as a monotherapy treatment for
  relapsing forms of multiple sclerosis (MS) to
  slow the progression of disability and reduce the
  frequency of clinical relapses.

10
Soliris

• Used to reduce hemolysis in patients with
  paroxysmal nocturnal hemoglobinuria (PNH).

11
Remicade

• Used to treat rheumatoid arthritis, ankylosing
  spondylitis, crohns disease (regional
  enteritis), psoriatic arthropathy, psoriasis, and
  ulcerative colitis.
• NOTE PA is only required when 50 or more units
  are requested due to patients weight.

12
Reclast

• Used to treat postmenopausal osteoporosis and
  Pagets disease of the bone in both men and women.

13
Torisel

• Torisel is indicated for the treatment of renal
  cell carcinoma (RCC).

14
How are Requests Submitted?

• Requests for medications are submitted via the
  GHP Web Portal.
• To register for the Web, go to
• www.ghp.georgia.gov for instructions
• or call
• the Customer Interaction Center
• 800-766-4456 (toll free).

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PA Types

• Utilize the following online forms to request
  medications prior authorization (PA).
• Medications PA Physician Office
• Medications PA Facility Setting

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Which PA Type to Use?

• Medications Physician Office
• Medications provided in a doctors office.
• Requesting provider is a physician or related
  practitioner.
• Medications Facility Setting
• Medications provided in an outpatient
  hospital. Requesting provider is an outpatient
  hospital.

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Authorization Periods
18
Code Entry Restrictions

• Only medication codes may be entered on a
  Medications PA request.
• As of 1/1/2007, the NDC should be used.
• System will not permit entry of the medication
  procedure codes on any other PA type.

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National Drug Codes
20
National Drug Codes
21
Additional Information

• An Additional Information web page has been added
  to each PA type to capture code-specific clinical
  information. Note Tysabri does not have an
  additional information page (this is subject to
  change).
• Each medication code has a different Additional
  Information page.

22
Medications PA Process

• When submitted, the case is pended (suspended)
  and WRD Waiting Review Decision.
• Cases are reviewed by nurses utilizing DCH policy
  guidelines. Cases may also be referred to a
  physician for further review.
• Cases may be approved or denied. If denied,
  Providers may submit a request for
  reconsideration within 30 days of the denial
  notification. Reconsideration requests may be
  faxed to 678-527-3725 (this number is for medical
  reconsideration requests only).

23
Requesting Changes

• Providers may request changes to existing
  Medication PAs. The most expedient way is to
  submit a change request via the GHP web portal.
  Instructions for this process are located on the
  GMCF website www.gmcf.org

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Notification

• Written notifications are sent for each case
  whether approved or denied.
• Search for the status of a prior authorization
  request via the web