PHYSICIAN PRIOR APPROVAL PROTOCOL

HIP New York prescribers should call the respective Department of Pharmacy Services to discuss clinical parameters for issuance of a physician prior approval number (PPA number) for drugs not included in the HIP Drug Formulary for members whose benefit does not provide for a three-tier non-formulary option. This should be done before sending the member to the pharmacy. It is important to remember that each new prescription for a medication requires a NEW PPA number.

Physicians and other prescribers should be prepared to answer the following questions:

• His/her name and license number
• Name of the member and HIP Identification number
• The name and strength of the drug
• Quantity to be dispensed and days supply
• Diagnosis
• Reason member can’t utilize the therapeutically equivalent formulary agent

Once approved, a PPA number will be assigned as follows:

• Members needing maintenance+ drugs are given up to a one year supply of medication or for the life of the prescription, whichever is less. Medication is dispensed in quantities of a 90-day supply at a time.
• Members needing non-maintenance+ drugs are given up to 30 day supply at a time.

This PPA number must then be legibly placed on the face of the prescription. This prescription can then be given to the member to fill at any HIP corporate or participating pharmacy.

In the event that a physician prior approval number is not obtained by the prescriber prior to the member going to fill the prescription, the pharmacist will contact the prescriber. If in the prescriber’s medical judgment, the member cannot utilize the formulary agent which does not require a prior approval, then the prescriber will be responsible for contacting Pharmacy Services and the procedure outlined above must be followed. This same procedure also must be followed if the member directly contacts his/her prescriber stating that the pharmacy has declined filling his/her prescription.

Pharmacy Services hours of operation:

HIP New York: Monday through Friday - 8:30 am to 6:00 pm.

At all other times pharmacists will be instructed to dispense a two - to five- day supply of medication. This will avoid interruption of the prescribed course of therapy. In addition, pharmacists will be directed to contact Pharmacy Services on the next business day to obtain prior approval. At that time, applicable policy will be reviewed with the pharmacy. In these cases the pharmacy will be reimbursed according to established policies and procedures.

+ Based on HIP’s list of maintenance and non-maintenance medications