Some Hospital Specialty Physician-Administered Drugs (PADs) require approval of a member specific prior authorization (PA) prior to administration in the inpatient and outpatient hospital settings. Appendix Z lists all Hospital Specialty Drug PADs requiring a PA, in addition to coverage standards.
Due to current limitations, PA Requests (PARs) cannot be reviewed after hours, on weekends or during state holidays and retro PAs are not usually accepted. Should an urgent case arise after hours, on a weekend or during a state holiday, a retro PA will be accepted and reviewed after treatment has been rendered.
Providers can access the PAR forms on the PAD Resources webpage. Please complete the most applicable PAR form for the PAD being requested and place of administration, then submit with appropriate clinical documentation for consideration. Once the completed PAR is received, the Department will communicate a response of an approval, denial or request for additional information within 24-hours, excluding weekends and state holidays. If any required documentation or information is missing, an additional email will be sent from the Department within 24-hours of receipt of the request. The requested information must be received by the Department for the review of the request to continue.
The PAR forms are to be completed and submitted with appropriate additional documentation, including, but not limited to: clinical notes, genetic testing information, letter of medical necessity, and specialty evaluations. All documentation is to be emailed to one of the applicable following email addresses:
- For Spinraza requests - HCPF_nusinersen@state.co.us
- For all other requests - HCPF_pharmacypad@state.co.us
If the request is approved, the Department will send an email with the following information:
- Medicaid ID
- Approval Date
- End Date
- Units Approved
- Drug Requested
- Procedure Code
- Diagnosis
The authorization number will be emailed with the above information or in a subsequent email once the approval has been loaded into the Department’s Medicaid Management Information System (MMIS). Approval of a PA does not guarantee payment.
If the request is denied, a notification email will be sent with the following information:
- Medicaid ID
- Denial Date
- Drug Requested
- Procedure Code
- Diagnosis
- Denial Reason
A denial letter will be mailed to the Member and the Provider. Please ensure all contact information is up-to-date within the MMIS. The member or a designated representative will be able to pursue the appeals process, pursuant to the information within the denial letter. If the denial letter is not received or a duplicate is needed, and for all other questions, please contact HCPF_PAD@state.co.us.