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Related post: MAINECARE BENEFITS MANUA L SECTION 80 PHARMACY SERVICES 05 COVERED SERVICES (cont.) Prior to consideration for authorization, the member's physicia must supply the following additional documentation in writing: A description of the attempts made to employ other oral measures to correct the risk/condition ; supplement used ; time frame of use ; reason for failure . Documentation that other oral measures are contraindicated and the reason why must also be submitted . Prior authorization may be effective for up to twelve (12) months as determined by medical criteria and documentation of ongoing medical Maine Care will not cover specified nutritional support products as part or all of a voluntary weight loss program . Effective2. Lactulose, and its analogs, for members with portal encephalopath or cirrhosis or as a laxative with written documentation from a physician of treatment failure with use of standard laxative therapy and demonstrated cost Drugs for the treatment of tuberculosis when authorized by the Bureau of Health (see 80 .06 (H)) . Drugs not found on the formulary or drugs not described as a covered service in Section 80 .05 will be approved, in compliance with OBRA 90, only where no other drugs found on the formulary or otherwise reimbursed by the MaineCare program will adequately treat the condition presented or where only a new drug not found on the formulary will prevent a higher and more costly level of care This service will be approved F. Filling of Insulin Syringes by Pharmacy Providers only when the prescriber can demonstrate, with documented medical justification, cost effectiveness and that the use of this service is medically necessary for effective care of the member. (See80 .09 (G) (1)(a)(iv) .) Anorexic or certain weight loss drugs may be prior authorized by the Department when used to treat comorbid conditions . H. Prescription, single dose laxatives are covered when necessary for Effective conducting diagnostic tests in a non-hospital setting. MAINECARE BENEFITS MANUA L SECTION 80 PHARMACY SERVICES 05 COVERED SERVICES (cont.) The Maine Care DUR Committee may recommend additional drugs for prior authorization, provided that in all instances Maine Care members shall be assured access to all medically necessary Public notice shall be given of all DUR Committee The DUR Committee shall consider the clinical appropriateness of Additional prior authorizations shall not take effect until 45 days after written notification is given to prescribers and The Department shall provide prescribers by mail at least quarterly with the list of drugs subject to prior authorization and such information shall be posted on a website designated by the Department. 05-4 Drugs Covered for Certain Conditions/Procedures Only Reimbursement for the following drugs will be made only for the conditions described and only when the prescriber has written the diagnosis on the prescription patient living in a nursing facility or an ICF-MR the diagnosis must only be noted in the patient's chart. To the extent that any of the drugs listed in this subsection (80 05-3, such prior authorization is not would require prior authorization under 80 Methylphenidate and dextroamphetamine for attention deficit disorders or Legend cough & cold preparations and decongestants for sinusitis, otitis media, emphysema or asthma only . C. B-12 for documented pernicious anemia or megaloblastic anemia only D. Aspirin, buffered aspirin, enteric coated aspirin and acetaminophen for Effective arthritis or heart disease. Multi-vitamins and vitamin E for cystic fibrosis. 2/4/02 1 tr ( t al fatIure, rena anspan F. The following oral drugs are covered for chronic ren Aluminum Carbonate Gel, Aluminum Hydroxide, Bisacodyl, B vitamins with C, calcium products including calcium oyster shell, Calcitriol, Calcifediol, DHT (Dihydrotachysterol), Docusate w/Casanthranol Effective Ergocalciferol 50,000u, iron containing products, Magaldrate folic acid, phosphorous replacement products, Psyllium 2/4/02 vitamins with ling Hydrophilic Lomefloxacin Eye Drops Mucilloid, thiamin . MAINECARE BENEFITS MANUA L SECTION 80 PHARMACY SERVICES 05 COVERED SERVICES (cont.) The following drugs are covered for members with quadriplegia Antacids, ascorbic acid, Bisacodyl, calcium oyster shell, Docusate w/Casanthranol, fleet enemas, glycerin suppositories, lubricating jelly, mineral oil, multivitamins, povidone iodine gel, Psyllium Hydrophilic Mucilloid, stress vitamins, and vitamin C & D. The following drugs are not reimbursed by the Maine Care program: Anorexic, or certain weight loss drugs, except as noted under Section 80.05. Vitamins and vitamin combinations (except prenatal vitamins as allowed under 05-1 (C) and vitamins covered for dialysis and members with 2/4/02 quadriplegia and paraplegia or when the criteria in Section 80 Effective Section 80.05-4(E) are met) . Hexachlorophene scrubs for nursing facility patients. Products listed as part of the per diem rate of reimbursement in Chapter II, Section 67 "Nursing Facility Services" or as defined in Section 50 "ICF-MR Services" or as defined in Section 60 "Medical Supplies and Durable Medical Equipment" of th Effective Maine Care Benefits Manual or as defined in Attachment A or B of the Agreement 2/4/02 between the Department and an assisted living facility. Drugs discontinued or recalled by the manufacturers. Less than Effective Drugs as defined by the Food and Drug Administration are not covered under the Maine Care State Plan, therefore, these drugs will Effective not be deducted from the assessment of the nursing facility resident. Drugs prescribed for TB (these are normally available from the Bureau of Health's Maine Care coverage is only available after referral Tuberculosis program free of charge) from the Bureau of Health and Maine Care prior authorization. 05-1(B) and when the criteria in Section Over-the-counter drugs except drugs listed in 80 80.05-3 are met . Any drug that is for experimental use or prescribed for indications other than those approved under OBRA 90 guidelines or have no Food and Drug Administration (FDA) sanctioned or approved indications. MAINECARE BENEFITS MANUA L SECTION 80 PHARMACY SERVICES4/1/7 9 80.07 POLICIES AND PROCEDURES (cont.) 80.07-3 Authorization Prior to Provision A. The Department will notify prescribers of the drugs that are subject to prior authorization and will provide them with forms for requesting authorization. The forms will also be available on a website designated by the Department. B. The requesting prescriber must complete the form applicable to the drug for which authorization is sought. The prescriber must send the completed form to the Department or its designee, as instructed by the Department, by mail, fax or by hand delivery . C. During regular business days, the Department or its designee will respond to a completed request for prior authorization by fax, telephone or other telecommunications device within 24 hours of receipt. The response will indicate whether or not the Buy Lomefloxacin drug will be added as a limited benefit Effectivefor that member according to the standards set forth in Section 80.05-3 . 2/4/02If a request is approved, such approval may be valid for up to one year, at which time a new prior authorization will be required. D. In an emergency situation, including weekends, holidays, or any other time that the Department or its designee is not able to respond to a completed prior authorization request within 24 hours of receipt, the pharmacist is authorized to provide a 96-hour supply of any prescribed drug that is a covered drug as defined in Section 80 .05. The Department or its designee shall respond to a completed request under this subpart on the next regular business day. The provision of a 96- hour supply under this subpart does not relieve the prescriber of the obligation to complete and submit the prior authorization request form. E. In the event that a prescriber fails to submit a completed form for a drug requiring prior authorization, the Department or its designee may authorize the pharmacy to dispense a one-time 34-day supply of the prescribed drug. The authorization of a 34-day supply under this provision does not relieve the prescriber of the obligation to complete and submit the prior authorization request form. If the prescriber has still failed to submit a completed prior authorization request by the end of the additional 34-day period, any refills of that prescription will be considered by the Department on a case-by-case basis. MAINECARE BENEFITS MANUA L SECTION 80 PHARMACY SERVICES4/1/79 80.07 POLICIES AND PROCEDURES (cont F. In completing the prior authorization request form, any prescriber who has an individual DEA number must use that identifier, rather than the number assigned to the institution for which he or she works or in which he or she Effectivetreats Maine Care members on an outpatient basis. Compliance with the following dispensing policies is required: A. Dispensing practices must be in accordance with the best medical, pharmaceutical and economical practice. B. Generic drugs as rated A in the current edition of the FDA Orange Book must be dispensed in accordance with State law, if available at a lower cost than the brand name product, unless: 1) the practitioner writes the words "Medically Necessary" in his/her own handwriting on the face of the prescription or the prescriber's order sheet for institutionalized patients, o r 2) for those prescribers who use automated systems to generate their prescriptions, the words "Medically Necessary" may be printed on the prescription or the prescriber's order sheet. The printed box on the form or order form that could be checked by the prescriber to indicate that a name brand is necessary is not acceptable. C. Single source, brand multisource or co-licensed drugs must be dispensed in quantities not to exceed a 34-day supply. FDA ' A-rated generic drugs must be dispensed in quantities sufficient to effect optimum economy, up to 90 days. Pharmacists will not be reimbursed for split prescriptions unless necessary to meet Maine Care policy, including but not limited to dispensing a 34-day supply. Also see Section 80.09. Where unit of use Lomefloxacin Hydrochloride packaging prevents the pharmacist from measuring a 34-day supply (e.g., ointments, eyedrops, insulin and inhalers) prescriptions shall be dispensed in a size consistent with a 34-day supply. D. Payment for medications dispensed in quantities in lesser or greater amounts than therapeutically reasonable may be withheld pending contact with the prescriber to determine justification for the amount. E. All prenatal vitamins must be dispensed in quantities of one hundred with no more than three refills. 80.07 POLICIES AND PROCEDURES (cont.)
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