Global Prior Authorization Criteria

Qualifying Criteria for the Global Prior Authorization Policy

1. Clients must have a focal point of care
   
   A focal point of care is a provider or group of providers from whom a client receives the majority of their scheduled primary care, and is the place where care coordination occurs. Having a focal point of care minimizes risks of medication duplication among multiple prescribers and helps ensure that the prescriber is familiar with the complex needs of the client. In general, the focal point of care conducts medication reconciliations at least annually and as needed during care transitions, regularly scheduled age-appropriate preventative care visits, and conducts a complete review of the client’s history at least annually.
    
2. Clients must be at high risk for drug-drug interactions.
   
   This includes clients taking eight or more medications NOT including over the counter products (OTC products not subject to this exclusion include classes on the Preferred Drug List or taking 3 or more high risk medications including: immunosuppressant agents, insulin (all forms considered as one medications), digoxin, and anticoagulants.
    
3. Clients must have one of the following diagnoses and not be Medicare/Medicaid dual eligible clients:
   1. HIV/AIDS- taking antiretroviral therapy
   2. Severe chronic schizophrenia as designated by the following ICD10 codes:
      1. F20.1 chronic disorganized schizophrenia
      2. F20.2 chronic catatonic schizophrenia
      3. F20.0 chronic paranoid schizophrenia 
      4. F25.9 chronic schizoaffective disorder
   3. Severe bipolar disorder as designated by the following ICD10 codes:
      1. F30.13 without psychotic behavior and F30.2 with psychotic behavior, manic affective disorder recurrent episode, severe
      2. F33.2 without psychotic behavior and F33.3 with psychotic behavior major depressive affective disorder recurrent episode
      3. F31.13 without psychotic behavior and F31.2 with psychotic behavior bipolar 1 disorder, most recent episode (or current) manic, severe
      4. F31.4 without psychotic behavior and F31.5 with psychotic behavior bipolar 1 disorder, most recent episode (or current) depressed, severe
      5. F31.63 without psychotic behavior and F31.64 with psychotic behavior, bipolar 1 disorder, most recent episode (or current) mixed, severe
   4. Traumatic brain injury – an injury caused by a blow or jolt to the head, penetration of the head, or violent shaking, that disrupts the function of the brain, resulting in long-term and lifelong need for help in performing activities of daily living.
   5. Developmental disability – manifested before age 22 and attributable to:
      1. Intellectual Developmental Disorder - must have an IQ of 75 or below and impairments in adaptive behavior in the 3 domains of conceptual, social, and practical skills.
      2. Cerebral palsy (G80.8 and G80.9)
      3. Epilepsy (G40.909) - severe, long-term or lifelong need for help in performing activities of daily living

      4. Autism – low functioning (F84.0) severe, long-term or lifelong need for help in performing activities of daily living

         These diagnoses include life-long disability, inability to live independently, severe communication difficulties and profound intellectual disability.

4. Client does NOT have Hepatitis C and/or Multiple Sclerosis and/or Cystic Fibrosis
   
   Medications provided as part of a per diem by a nursing facility and therefore are non-coverable by a global PA. The products are listed on 10 CCR 2505-10 including:
   
   Artificial tears, aspirin, acetaminophen, ibuprofen, and other non-prescription analgesics; cough and cold supplies including cold tablets, decongestants, cough syrup/tablets; douches, evacuant suppositories, laxative stool softeners, enemas; first aid supplies such as alcohol, hydrogen peroxide, merthiolate and other antiseptics/germicides, betadine, phisohex, chlorhexidine gluconate, povidone/iodine solution and wash, Epsom salt; lubricants rubbing compounds and ointments such as petroleum jelly, bag balm, other body lotions for treatment of dry skin or skin breakdowns, bacitracin ointment and other ointments used in treatment of wounds; vitamins (multi and single) and mineral supplements.