Drug Utilization Review. Compliance with Formularies and Provider ----------------------------------------------------------------- Manual. Provider shall (1) cooperate with ESI's procedures for drug ------ utilization review and generic substitution, as set forth from time to time in the Provider Manual; (2) comply with ESI's procedures for calling prescribers to facilitate generic substitution and Formulary compliance, and other programs established by a Sponsor; and (3) comply with the Provider Manual. Provider shall use commercially reasonable efforts to comply with the applicable Formulary when dispensing Covered Medications to Members. Without limiting the generality of the foregoing, in no event will Provider (i) attempt to switch a Member's prescription to a drug that is not a Formulary drug on the applicable Formulary, except for generic substitution opportunities or where required by medical necessity. Provider agrees that ESI's manufacturer agreements, therapeutic programs and formularies take precedence with the manufacturers over any such agreements or programs to which Provider is a party with respect to Covered Medications dispensed to Members. Provider will not implement any substitution program for Members of Prescription Drug Programs that is inconsistent with such Prescription Drug Program, including the applicable Formulary.
Drug Utilization Review. The Health Plan shall design and implement a drug utilization review (DUR) program designed to encourage coordination between an enrollee’s primary care physician and a prescriber of a psychotropic or similar prescription drug for behavioral health problems. The Health Plan’s DUR program shall identify those medications for other serious medical conditions (such as hypertension, diabetes, neurological disorders, or cardiac problems), where this is a significant risk to the enrollee posed by potential drug interactions between drugs for these conditions and behavioral-related drugs. After the WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract Health Plan identifies the potential for such problems, the Health Plan’s DUR program shall notify all related prescribers that certain drugs may be contra-indicated due to the potential for drug interactions and shall encourage the prescribers to coordinate their care. Notice may be provided electronically or via mail, or by telephonic or direct consultation, as the Health Plan deems appropriate.
Drug Utilization Review. Benecard will review both concurrently and retrospectively Claims for potential fraud, waste, abuse, and clinical appropriateness. Claims are reviewed daily from the previous day to ensure such Claims are being prescribed based on clinically appropriate and FDA approved guidelines, including but not limited to, duplicate therapy, refill too soon, gender appropriate, age appropriate, cost and quantities. Fraud, waste and abuse Claims are also reviewed retrospectively each calendar quarter, reported and tracked until resolution of the case is completed and when applicable, notified to the Group.
Drug Utilization Review. Both parties agree to maintain and participate in, the Drug Utilization Management Program. This program shall be administered in accordance with applicable Benefit Program requirements and shall include medication therapy management programs.
Drug Utilization Review. Xxxxx will provide concurrent drug utilization review services through edits applied during Claims Processing in order to assist the dispensing pharmacist and prescribing physician in identifying potential drug interactions, incorrect prescriptions or dosages, and certain other circumstances that may be indicative of inappropriate prescription drug usage. Xxxxx’x utilization review services are not intended to substitute for the professional judgment of the prescriber, the dispensing pharmacist or any other health care professional providing services to the Member. Client or its third party designee (as applicable) will have the final responsibility for all decisions with respect to coverage of a Claim and the benefits allowable under the Plan, including determining whether any rejected or disputed claim will be allowed.
Drug Utilization Review. The Health Plan shall design and implement a drug utilization review (DUR) program designed to encourage coordination between an enrollee’s primary care physician and a prescriber of a psychotropic or similar prescription drug for behavioral health problems. The Health Plan’s DUR program shall identify those medications for other serious medical conditions (such as hypertension, diabetes, neurological disorders, or cardiac problems), where this is a significant risk to the enrollee posed by potential drug interactions between drugs for these conditions and behavioral-related drugs. After the Health Plan identifies the potential for such problems, the Health Plan’s DUR program shall notify all related prescribers that certain drugs may be contra-indicated due to the potential for drug interactions and shall encourage the prescribers to coordinate their care. Notice may be provided electronically or via mail, or by telephonic or direct consultation, as the Health Plan deems appropriate. HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
5. Outreach Program – The Health Plan shall have an outreach program including referral and other resources designed to assist PCPs in the identification, management and treatment of:
a. Enrollees with severe and persistent mental illness;
b. Children/adolescents with severe emotional disturbances; and
c. Enrollees with clinical depression.
Drug Utilization Review. The Health Plan shall design and implement a drug utilization review (DUR) program designed to encourage coordination between an enrollee’s primary care physician and a prescriber of a psychotropic or similar prescription drug for behavioral health problems. The Health Plan’s DUR program shall identify those medications for other serious medical conditions (such as hypertension, diabetes, neurological disorders, or cardiac problems), where this is a significant risk to the enrollee posed by potential drug interactions between drugs for these conditions and behavioral-related drugs. After the Health Plan identifies the potential for such problems, the Health Plan’s DUR program shall notify all related prescribers that certain drugs may be contra-indicated due to the potential for drug interactions and shall encourage the prescribers to coordinate their care. Notice may be provided electronically or via mail, or by telephonic or direct consultation, as the Health Plan deems appropriate. WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform Contract
5. Outreach Program – The Health Plan shall have an outreach program including referral and other resources designed to assist PCPs in the identification, management and treatment of:
a. Enrollees with severe and persistent mental illness;
b. Children/adolescents with severe emotional disturbances; and
c. Enrollees with clinical depression.
Drug Utilization Review. CHLIC shall perform a concurrent Drug Utilization Review (“DUR”) analysis of each prescription submitted for processing, which may include: (1) prescribed dosage within a safe range; (2) drug-to-drug interaction; (3) drug-to- allergy interaction; (4) age-to-drug interaction;
