2012 New York Consolidated Laws
PBH - Public Health
Article 2-A - PRESCRIPTION DRUGS
Title 1 - (270 - 277) PREFERRED DRUG AND CLINICAL DRUG REVIEW PROGRAMS
273 - Preferred drug program prior authorization.

 
    § 273. Preferred drug program prior authorization. 1. For the purposes
  of  this  article,  a prescription drug shall be considered to be not on
  the preferred drug list if it is a non preferred drug.
    2. The preferred drug program shall make available a twenty-four  hour
  per  day,  seven  days  per  week  telephone call center that includes a
  toll-free telephone line and dedicated  facsimile  line  to  respond  to
  requests   for  prior  authorization.  The  call  center  shall  include
  qualified health care professionals who shall be  available  to  consult
  with  prescribers  concerning  prescription  drugs  that  are not on the
  preferred drug list. A  prescriber  seeking  prior  authorization  shall
  consult  with  the  program  call  line to reasonably present his or her
  justification for the prescription  and  give  the  program's  qualified
  health care professional a reasonable opportunity to respond.
    3. (a) When a patient's health care provider prescribes a prescription
  drug  that  is  not  on  the  preferred  drug list, the prescriber shall
  consult with the program to  confirm  that  in  his  or  her  reasonable
  professional  judgment,  the  patient's clinical condition is consistent
  with the criteria for approval of the non-preferred drug. Such  criteria
  shall include:
    (i) the preferred drug has been tried by the patient and has failed to
  produce the desired health outcomes;
    (ii)  the  patient  has  tried  the preferred drug and has experienced
  unacceptable side effects;
    (iii) the patient has been stabilized  on  a  non-preferred  drug  and
  transition to the preferred drug would be medically contraindicated; or
    (iv)  other  clinical  indications identified by the committee for the
  patient's  use  of  the  non-preferred   drug,   which   shall   include
  consideration  of  the  medical  needs of special populations, including
  children,  elderly,  chronically  ill,  persons   with   mental   health
  conditions, and persons affected by HIV/AIDS.
    (b)  In  the  event  that  the  patient  does not meet the criteria in
  paragraph (a) of this subdivision, the prescriber may provide additional
  information to the program to justify the use  of  a  prescription  drug
  that  is  not  on  the  preferred drug list. The program shall provide a
  reasonable opportunity for a prescriber to reasonably present his or her
  justification of prior authorization. If, after  consultation  with  the
  program, the prescriber, in his or her reasonable professional judgment,
  determines  that  the  use  of  a  prescription  drug that is not on the
  preferred drug list is warranted, the prescriber's  determination  shall
  be final.
    (c)  If a prescriber meets the requirements of paragraph (a) or (b) of
  this subdivision, the prescriber shall be  granted  prior  authorization
  under this section.
    (d)  In  the instance where a prior authorization determination is not
  completed within twenty-four hours of the original  request,  solely  as
  the  result of a failure of the program (whether by action or inaction),
  prior authorization shall be immediately and automatically granted  with
  no further action by the prescriber and the prescriber shall be notified
  of  this  determination.  In  the  instance  where a prior authorization
  determination is not completed within twenty-four hours of the  original
  request  for  any  other  reason,  a  seventy-two  hour  supply  of  the
  medication shall be approved by the program and the prescriber shall  be
  notified of this determination.
    4.  When,  in  the  judgment  of  the prescriber or the pharmacist, an
  emergency condition exists, and the prescriber  or  pharmacist  notifies
  the  program  that  an  emergency  condition  exists, a seventy-two hour
  emergency supply of the drug prescribed shall be immediately  authorized
  by the program.

    5. In the event that a patient presents a prescription to a pharmacist
  for  a  prescription drug that is not on the preferred drug list and for
  which the  prescriber  has  not  obtained  a  prior  authorization,  the
  pharmacist shall, within a prompt period based on professional judgment,
  notify  the  prescriber.  The  prescriber  shall, within a prompt period
  based on professional judgment, either seek prior authorization or shall
  contact the  pharmacist  and  amend  or  cancel  the  prescription.  The
  pharmacist shall, within a prompt period based on professional judgment,
  notify  the patient when prior authorization has been obtained or denied
  or when the prescription has been amended or cancelled.
    6. Once prior authorization of a prescription for a drug that  is  not
  on the preferred drug list is obtained, prior authorization shall not be
  required for any refill of the prescription.
    7.  No  prior  authorization under the preferred drug program shall be
  required when a prescriber prescribes a drug on the preferred drug list;
  provided, however, that the commissioner may identify such  a  drug  for
  which  prior authorization is required pursuant to the provisions of the
  clinical drug review  program  established  under  section  two  hundred
  seventy-four of this article.
    8.  The  department  shall monitor the prior authorization process for
  prescribing patterns which are suspected of endangering the  health  and
  safety  of  the  patient  or  which demonstrate a likelihood of fraud or
  abuse. The department shall take any and all actions otherwise permitted
  by law to investigate such prescribing patterns, to take remedial action
  and to enforce applicable federal and state laws.
    9. No prior authorization under the preferred drug  program  shall  be
  required  for any prescription under EPIC until the panel has made prior
  authorization applicable to EPIC under section two hundred  seventy-five
  of this article.