Section 400.109h - Prior authorization for certain prescription drugs not required; drugs under contract between department and health maintenance organization; definitions.
THE SOCIAL WELFARE ACT (EXCERPT)
Act 280 of 1939
400.109h Prior authorization for certain prescription drugs not required; drugs under contract between department and health maintenance organization; definitions.
Sec. 109h.
(1) If the department of community health develops a prior authorization process for prescription drugs as part of the pharmaceutical services offered under the medical assistance program administered under this act, it shall not require prior authorization for the following single source brand name, generic equivalent of a multiple source brand name, or other prescription drugs:
(a) A central nervous system prescription drug that is classified as an anticonvulsant, antidepressant, antipsychotic, or a noncontrolled substance antianxiety drug in a generally accepted standard medical reference.
(b) A prescription drug that is cross-indicated for a central nervous system drug exempted under subdivision (a) as documented in a generally accepted standard medical reference.
(c) Unless the prescription drug is a controlled substance or the prescription drug is being prescribed to treat a condition that is excluded from coverage under this act, a prescription drug that is recognized in a generally accepted standard medical reference as effective in the treatment of conditions specified in the most recent diagnostic and statistical manual of mental disorders published by the American psychiatric association. The department or the department's agent shall not deny a request for prior authorization of a controlled substance under this subdivision unless the department or the department's agent determines that the controlled substance or the dosage of the controlled substance being prescribed is not consistent with its licensed indications or with generally accepted medical practice as documented in a standard medical reference.
(d) A prescription drug that is recognized in a generally accepted standard medical reference for the treatment of and is being prescribed to a patient for the treatment of any of the following:
(i) Human immunodeficiency virus infections or the complications of the human immunodeficiency virus or acquired immunodeficiency syndrome.
(ii) Cancer.
(iii) Organ replacement therapy.
(iv) Epilepsy or seizure disorder.
(2) This section does not apply to drugs being provided under a contract between the department and a health maintenance organization.
(3) As used in this section:
(a) “Controlled substance” means that term as defined in section 7104 of the public health code, 1978 PA 368, MCL 333.7104.
(b) “Cross-indicated” means a drug which is used for a purpose generally held to be reasonable, appropriate, and within community standards of practice even though the use is not included in the federal food and drug administration's approved labeled indications for that drug.
(c) “Department” means the department of community health.
(d) “Prescriber” means that term as defined in section 17708 of the public health code, 1978 PA 368, MCL 333.17708.
(e) “Prescription” or “prescription drug” means that term as defined in section 17708 of the public health code, 1978 PA 368, MCL 333.17708.
(f) “Prior authorization” means a process implemented by the department of community health that conditions, delays, or denies the delivery of particular pharmaceutical services to medicaid beneficiaries upon application of predetermined criteria by the department or the department's agent for those pharmaceutical services covered by the department on a fee-for-service basis or pursuant to a contract for those services. The process may require a prescriber to verify with the department or the department's agent that the proposed medical use of a prescription drug being prescribed for a patient meets the predetermined criteria for a prescription drug that is otherwise covered under this act or require a prescriber to obtain authorization from the department or the department's agent before prescribing or dispensing a prescription drug that is not included on a preferred drug list or that is subject to special access or reimbursement restrictions.
History: Add. 2004, Act 248, Imd. Eff. July 23, 2004
Popular Name: Act 280