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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-35

Effective Date: 07/01/05

35 Approval Date: _____________/06 B. Coverage includes home infusion therapy which is covered consistent with limits and requirements set out within home health services.

C. Effective June 1, 2004, pursuant to § 1927 of the Act and 42 CFR § 440.230, the Department shall require the prior authorization of legend drugs when both institutionalized and non-institutionalized FAMIS enrollees are prescribed high numbers of legend drugs. Over-the-counter drugs and legend drug refills shall not count as a unique prescription for the purposes of prior authorization as it relates to the threshold program.

Prior authorization shall be required for non-institutionalized FAMIS enrollees whose current volume of prescriptions meet the identified threshold limits as defined by the agency’s guidance documents for pharmacy utilization review, limitations, and the prior authorization program. All recipients subject to these prior authorization limits shall be given advance notice of such limits and shall be advised of their rights to appeal. Such appeals shall be considered and responded to pursuant to 12 VAC 30-110-10 et. seq.

Prior authorization shall be required for institutionalized FAMIS enrollees whose current volume of prescriptions meet the identified threshold limits as defined by the agency’s guidance documents for pharmacy utilization review, limitations, and prior authorization program. All recipients subject to these prior authorization limits shall be given advance notice of such limits and shall be advised of their rights to appeal. Such appeals shall be considered and responded to pursuant to 12 VAC 30-110-10 et. seq.

Prior authorization shall consist of prospective and retrospective drug therapy review by a licensed pharmacist to ensure that all predetermined clinically appropriate criteria, as established by the department, have been met before the prescription may be dispensed. Prior authorization shall be obtained through a call center staffed with appropriate clinicians, or through written or electronic communications (e.g., faxes, mail). Responses by telephone or other telecommunications device within 24 hours of a request for prior authorization shall be provided. The dispensing of 72-hour emergency supplies of the prescribed drug may be permitted and dispensing fees shall be paid to the pharmacy for such emergency supply.

Exclusion of protected institutions from pharmacy threshold prior authorization. For the purposes of threshold prior authorization, nursing facility residents do not include residents of the Commonwealth’s mental retardation training centers. For the purposes of threshold prior