The information required at the time prior authorization is requested includes the following:
•The name and card number of the recipient.
•The prescriber’s license number.
•The specifics of the prescription, including drug name, strength, quantity, directions, number of days’ supply, and duration.
•Clinical information to support the medical necessity for the medication.
•Diagnosis codes or diagnosis.
The clinical information provided during the review must be verifiable within the patient’s medical record. Upon retrospective review, the Department of Human Services may seek restitution for the payment of the prescription and any applicable restitution penalties from the prescriber if the medical record does not support the medical necessity for the prescription.