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MF Clinic Administered Meds with Prior Auth (115.001)

MF Clinic Administered Meds with Prior Auth (115.001) - Policies, Administrative, UWMF, UWMF-wide, Pharmacy

115.001







MF Clinic Administered Meds w/Prior Auth



Category: UW Medical Foundation Policy
Policy Number: MF
Effective Date: August 1, 2006
Version:
Manual: Pharmacy (Clinical)
Section: Clinic Administered Meds w/Prior Auth


Policy Detail

PURPOSE:
To establish a system for managing the use of clinic administered medications in UWMF Clinics
with implementation of a prior authorization system.
POLICY:
In order to ensure that medications are utilized appropriately and in the most cost-effective
manner, a prior approval (prior authorization) process for selected medications has been
developed. Evidence-based clinical criteria for the use of these medications will be developed in
collaborations with UWMF physicians to guide the UWHC Center for Drug Policy (CDP) staff in
managing the prior authorization system. Administration of a medication that is supplied by the
patient will be prohibited with exceptions as noted and individually approved. This process will
improve patient care and reduce the cost of care. This policy is applicable to all UWMF clinics.
(Note UWHC policy # 13.21 applies the same standards to UWHC clinics.)
PROCEDURE:
I. All medications administered in a UWMF clinic or facility will be acquired and dispensed from a
UW Health pharmacy to ensure product integrity. Administration of a medication that is supplied
by the patient is prohibited.
1. The UWHC CDP may grant exceptions on a patient by patient basis or to a specific clinic.
These exceptions may be requested if the administration is made impractical through
the restrictions of this policy. The clinic exceptions will be reviewed by the UWHC
Pharmacy and Therapeutics Committee (P&T).
2. Should an exception be granted, the integrity of the drug product must be ensured.
o Inquires of the patient regarding product storage will be made.
o The medication will be examined by a pharmacist.
o The product may be shipped directly to the clinic or the pharmacy and stored
for the individual patient use.
o If exception is granted, products should be shipped as a unit of use rather than
a multidose vial when permitted.
II. Medications that are exempt from the prior authorization requirement of this
policy include
1. Chemotherapy and other adjunct medications utilized in UWMF Oncology Clinics.
2. Medications that are routinely used for acute situations.
III. A Pharmacist in the CDP will verify clinical appropriateness for clinic-
administered medications designated as requiring prior authorization against pre-established
criteria prior to dispensing of the product.
1. Appropriate criteria will be prospectively developed in an evidence based fashion for
medications designated as requiring prior authorization. Consensus among experts
within the UW Health system will be sought.
2. A subcommittee of the UWHC Pharmacy & Therapeutics Committee on behalf of all
UWMF clinics will approve criteria. Subcommittee members will include but are not


limited to:
o UWHC P & T members
o UWMF Faculty members
o UWMF Administration members
o UWHC Administration members
o Director of the UWHC Infusion Center or designee
o Director of the CDP or designee
o Ad-hoc committee members based on products being reviewed.
o Approval criteria will be sent to the UWHC P&T Committee for final approval.
o For less commonly used high cost products, clinical appropriateness will be
determined on a case by case basis using standard medical necessity criteria
(FDA labeling, compendial standing, availability of published evidence
supporting efficacy and safety etc.)
o A standard request form that does not include any specific criteria will be made
available through the UW Health web site.
o Until a web-based submission system is in place, the interim system for the
prior authorizations will be paper based.
o Ordering physicians will be required to provide clinical justification for use and
follow the procedure described below the submission of the request.
o In certain clinical situations, the medication may be approved for short-term
use only and continued use may require additional authorization.
IV. A ist of medications requiring prior authorization and their appropriate clinical criteria under
this policy will be maintained by the CDP and be available electronically on the UW Health web
site. In general, medications requiring prior approval include one or more of the following
criteria:
1. Medications that have an estimated (or actual) cost of $5000 or greater per patient per
course of therapy.
2. Medications with a high risk of inappropriate use.
3. Any others as specified by the CDP, with tentative prior authorization criteria as
approved by the Medical Director of Ambulatory Clinic Operations until complete clinical
review and approval by the P&T subcommittee.
V. When a physician wants to administer a medication requiring prior authorization in the clinic, a
prior authorization form must be completed by the prescribing clinic and sent via fax to the UW
Center for Drug Policy for review. Medications requiring prior authorization will not be dispensed
until a prior authorization request has been approved. Please refer to the flowchart at the end of
the policy for details.
1. The prior authorization forms outlining appropriate clinical criteria for use will be made
available to all clinics via the UW Health web site, as will the standard request form.
o Information to be documented on each prior authorization request includes but
not limited to:
 Prescriber Information (phone, fax, address)
 Patient name
 Medical record number
 Date of birth
 Insurance information
 Patient drug allergies
 Drug therapy requested (dosage, frequency,duration)
 Pertinent lab results
 Concomitant therapies
 Specific criteria for use that apply to individual patient
 Location where drug will be administered
 Planned date to be administered
 Desired Outcome
o Additional information may be requested for each specific drug as applies to
clinical criteria.
VI. A pharmacist in the CDP will review each request and determine if clinical criteria for use
have been met.

1. The prescriber may be contacted if more information about the patient is needed.
2. Requests will be reviewed and decisions made within 3 business days of request receipt.
It is required that prior authorization requests be submitted and approval granted
BEFORE the patient arrives for medication administration as detailed in the flowcharts at
the end of this policy.
VII. If approved, the CDP will communicate the approval with the prescriber’s office and the
pharmacy department servicing that clinic.
1. All approvals will be documented in a database maintained by CDP.
VIII. If the request is denied, the CDP will communicate the denial with the prescribing clinic,
pharmacy, and patient.
1. All denials will be documented in a database maintained by the CDP.
2. When a request is denied, the medication will not be dispensed for administration.
3. Denial notifications will include the reason for the denial and contact information if the
prescriber wishes to discuss the decision.
IX. Appeal of denials can be made by the prescriber to the CDP.
1. Denial notifications will include information on how to appeal the decision.
2. When appeals are received, the CDP will contact the Medical Director for Ambulatory
Clinic Operations with details of the denial and the appeal.
3. The appeal decision will be communicated to the prescriber by the CDP or by the
Medical Director for Ambulatory Clinic Operations and the decision documented in the
database maintained by the CDP.
WRITTEN BY: Mary Ann Steiner, PharmD, Center for Drug Policy
REVIEWED BY: Carrie Boeckelman, RPh, Pharmacy Manager
AUTHORIZATION:
Medical Director Date