Form V. C-1.0 - Minnesota Uniform Form For Prescription Drug Prior Authorization (Pa) Requests And Formulary Exceptions - 2010

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Minnesota Uniform Form for Prescription Drug Prior

Authorization (PA) Requests and Formulary Exceptions

InstRUCtIOns

Important: Please read all instructions and information before completing the form.

Please do not send this form to a patient’s employer or to the Minnesota Department of Health (MDH)

or to the Minnesota Administrative Uniformity Committee (AUC).

Note: This version of the form (C-1.0) is current as of July 2010, and supersedes the following previous versions of Minnesota Department of Health

forms for PA requests and formulary exceptions:

•

Example Minnesota Prescription Drug Prior Authorization (PA) Request Form, version 1.0 2/15/10

•

Minnesota Uniform Formulary Exception Form, version 1.0 September, 2009

This form will not change frequently. The form version number and most recent revision date are displayed in the lower right corner.

Overview:

The following form is made available by the Minnesota Department of Health (MDH) pursuant to statute, to facilitate exchanges of

information between prescribers and patients’ insurance carriers, HMOs, Pharmacy Benefits Managers (PBMs), or other payers* of

prescription drug claims.

Intended use and requirements:

The form is intended primarily for use by prescribers, or those designated and authorized to act on behalf of prescribers, to:

1. Request an exception to a prescription drug formulary.

Requests for formulary exceptions are requests to make nonformulary prescription drugs available to a patient as a

formulary drug.

• Laws 2010, chapter 336, section 4 requires that all health care providers must submit requests for formulary

exceptions using the uniform form, and that all payers must accept this form from health care providers. No later

than January 1, 2011, the uniform formulary exception form must be accessible and submitted by health care

providers, and accepted and processed by group purchasers, through secure electronic transmissions. Note: A

previous restriction in law that facsimile was not considered “secure electronic transmission” was removed in 2010.

2. Request a prior authorization (PA) for a prescription drug.

Prescription drug prior authorization requests are requests for pre-approval from a payer for specified medications or

quantities of medications.

• Laws 2010, chapter 336, section 5 requires that by January 1, 2015, drug PA requests must be accessible and

submitted by health care providers, and accepted by payers, electronically through secure electronic transmissions.

Additional Instructions:

Prescribers, or their designees, use parts A-F as applicable. Payers making the form available on their websites may

pre-populate section A. Payers use section G when responding to requests.

Payers may request additional information or clarification needed to process formulary exceptions and PA requests.

Payers may supply additional instructions or other relevant or legally required information with their response.

Complete section F when submitting prescription drug PA requests to the Minnesota Department of Human Services.

* Note: The term “payers” is used to avoid possible confusion. The electronic submission and acceptance requirements of Minnesota Statutes § 62J.497, subd. 4 and 5,

apply to “group purchasers”. The term “group purchaser” is defined in Minnesota Statutes § 62J.03, subd. 6 and can be considered more commonly as “payer”.

This form was approved by the Commissioner of the Minnesota Department of Health July, 2010

V. C-1.0 JUly2010