HCFA(now known as CMS) has no statutory or regulatory authority over States' PA programs, provided that therapeutic alternatives are available without PA. However, HCFA(now known as CMS) has some authority over process issues. For example, in response to complaints from advocacy groups on PA programs that were too active and involved cumbersome paperwork, HCFA(now known as CMS) performed a state-by-state analysis on atypical antipsychotics. HCFA(now known as CMS)'s research verified that some PA programs were indeed too active based on the criteria of "reasonable process." In response, HCFA(now known as CMS) sent a letter to States requiring a 24-hour response rate and 72-hour emergency drug supply for drugs that required prior authorization. Based on the number of complaints received by HCFA(now known as CMS), this action appears to have resolved many of the problem areas.
State Medicaid and Mental Health programs interviewed reported few drugs that required prior authorization, as would be expected for programs with open formularies. California requires PA for several non-formulary antidepressants, including citalopram, sertraline, venlafaxine, and mirtazapine. When required, any certified health care provider can request PA, and a response is obtained via fax in 24 hours. Medi-Cal reports that the system may take longer when the 20 consulting pharmacists who review PA requests are overwhelmed by request volume. All States require prior authorization for clozapine, as required by Federal law.
Within the DoD system, prior authorization programs vary by military treatment facility (MTF). On the base, primary care physicians, psychiatrists, pharmacists, physician assistants, and nurses can initiate a PA request. This request must be justified by safety and effectiveness arguments. The Pharmaceutical and Therapeutic Committee reviews PA requests. The VA requires no PA except for clozapine. A primary care physician or psychiatrist initiates all PA requests.