{"data":{"id":"us-ok/okla.-stat.-tit.-63-63-5030.5","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 63, § 63-5030.5","heading":"Drug prior authorization program - Conditions","body":"A. Except as provided in subsection F of this section, any drug\n\nprior authorization program approved or implemented by the Medicaid\n\nDrug Utilization Review Board shall meet the following conditions:\n\n1. The Medicaid Drug Utilization Review Board shall make note\n\nof and consider information provided by interested parties,\n\nincluding, but not limited to, physicians, pharmacists, patients,\n\nand pharmaceutical manufacturers, related to the placement of a drug\n\nor drugs on prior authorization;\n\n2. Any drug or drug class placed on prior authorization shall\n\nbe reconsidered no later than twelve (12) months after such\n\nplacement;\n\n3. The program shall provide either telephone or fax approval\n\nor denial within twenty-four (24) hours after receipt of the prior\n\nauthorization request; and\n\n4. In an emergency situation, including a situation in which an\n\nanswer to a prior authorization request is unavailable, a seventy-\n\ntwo-hour supply shall be dispensed, or, at the discretion of the\n\nMedicaid Drug Utilization Review Board, a greater amount that will\n\nassure a minimum effective duration of therapy for an acute\n\nintervention.\n\nB. In formulating its recommendations for placement of a drug\n\nor drug class on prior authorization to the Oklahoma Health Care\n\nAuthority Board, the Medicaid Drug Utilization Review Board shall:\n\n1. Consider the potential impact of any administrative delay on\n\npatient care and the potential fiscal impact of such prior\n\nauthorization on pharmacy, physician, hospitalization and outpatient\n\ncosts. Any recommendation making a drug subject to placement on\n\nprior authorization shall be accompanied by a statement of the cost\n\nand clinical efficacy of such placement;\n\n2. Provide a period for public comment on each meeting agenda.\n\nPrior to making any recommendations, the Medicaid Drug Utilization\n\nReview Board shall solicit public comment regarding proposed changes\n\nin the prior authorization program in accordance with the provisions\n\nof the Oklahoma Open Meeting Act and the Administrative Procedures\n\nAct; and\n\n3. Review Oklahoma-Medicaid-specific data related to\n\nutilization criterion standards as provided in division (1) of\n\nsubparagraph b of paragraph 2 of Section 5030.4 of this title.\n\nC. The Oklahoma Health Care Authority Board may accept or\n\nreject the recommendations of the Medicaid Drug Utilization Review\n\nBoard in whole or in part, and may amend or add to such\n\nrecommendations.\n\nD. The Oklahoma Health Care Authority shall immediately provide\n\ncoverage under prior authorization for any new drug approved by the\n\nUnited States Food and Drug Administration. If a new drug does not\n\nfall in a class that is already placed under prior authorization,\n\nthat drug must be reviewed by the Drug Utilization Review Board\n\nwithin one hundred (100) days of approval by the United States Food\n\nand Drug Administration to determine whether to continue the prior\n\nauthorization criteria.\n\nE. 1. Prior to a vote by the Medicaid Drug Utilization Review\n\nBoard to consider expansion of product-based prior authorization,\n\nthe Authority shall:\n\na. develop a written estimate of savings expected to\n\naccrue from the proposed expansion, and\n\nb. make the estimate of savings available, on request of\n\ninterested persons, no later than the day following\n\nthe first scheduled discussion of the estimate by the\n\nMedicaid Drug Utilization Review Board at a regularly\n\nscheduled meeting.\n\n2. The written savings estimate based upon savings estimate\n\nassumptions specified by paragraph 3 of this subsection prepared by\n\nthe Authority shall include as a minimum:\n\na. a summary of all paid prescription claims for patients\n\nwith a product in the therapeutic category under\n\nconsideration during the most recent month with\n\ncomplete data, plus a breakdown, as available, of\n\nthese patients according to whether the patients are\n\nresidents of a long-term care facility or are\nd by paragraph 3 of this subsection prepared by\n\nthe Authority shall include as a minimum:\n\na. a summary of all paid prescription claims for patients\n\nwith a product in the therapeutic category under\n\nconsideration during the most recent month with\n\ncomplete data, plus a breakdown, as available, of\n\nthese patients according to whether the patients are\n\nresidents of a long-term care facility or are\n\nreceiving Advantage Waiver program services,\n\nb. current number of prescriptions, amount reimbursed and\n\ntrend for each product within the category under\n\nconsideration,\n\nc. average active ingredient cost reimbursed per day of\n\ntherapy for each product and strength within the\n\ncategory under consideration,\n\nd. for each product and strength within the category\n\nunder consideration, where applicable, the prevailing\n\nState Maximum Allowable Cost reimbursed per dosage\n\nunit,\n\ne. the anticipated impact of any patent expiration of any\n\nproduct within the category under consideration\n\nscheduled to occur within two (2) years from the\n\nanticipated implementation date of the proposed prior\n\nauthorization expansion, and\n\nf. a detailed estimate of administrative costs involved\n\nin the prior authorization expansion including, but\n\nnot limited to, the anticipated increase in petition\n\nvolume.\n\n3. Savings estimate assumptions shall include, at a minimum:\n\na. the prescription conversion rate of products requiring\n\nprior authorization (Tier II) to products not\n\nrequiring prior authorization (Tier I) and to other\n\nalternative products,\n\nb. aggregated rebate amount for the proposed Tier I and\n\nTier II products within the category under\n\nconsideration,\n\nc. market shift of Tier II products due to other causes\n\nincluding, but not limited to, patent expiration,\n\nd. Tier I to Tier II prescription conversion rate, and\n\ne. nature of medical benefits and complications typically\n\nseen with products in this class when therapy is\n\nswitched from one product to another.\n\n4. The Medicaid Drug Utilization Review Board shall consider\n\nprior authorization expansion in accordance with the following\n\nMedicaid Drug Utilization Review Board meeting sequence:\n\na. first meeting: publish the category or categories to\n\nbe considered for prior authorization expansion in the\n\nfuture business section of the Medicaid Drug\n\nUtilization Review Board agenda,\n\nb. second meeting: presentation and discussion of the\n\nwritten estimate of savings,\n\nc. third meeting: make formal notice in the agenda of\n\nintent to vote on the proposed prior authorization\n\nexpansion, and\n\nd. fourth meeting: vote on prior authorization\n\nexpansion.\n\nF. The Medicaid Drug Utilization Review Board may establish\n\nprotocols and standards for the use of any prescription drug\n\ndetermined to be medically necessary, proven to be effective and\n\napproved by the United States Food and Drug Administration (FDA) for\n\nthe treatment and prevention of human immunodeficiency\n\nvirus/acquired immune deficiency syndrome (HIV/AIDS) without prior\n\nauthorization, except when there is a generic equivalent drug\n\navailable.","path":["OK Code","Title 63"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os63.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"71f7780ac4cfaa4d1446281abbf1112c276206254ede5252cf341ebf032da5da","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-63-63-5030.4a","next":"us-ok/okla.-stat.-tit.-63-63-5031"},"notice":"GroundRules: Original legal text. Not legal advice."}