Common use of Outpatient Pharmacy Clause in Contracts

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age twenty-one (21), and prenatal vitamins) are covered by FFS Medicaid. Hemophilia-related clotting factor drugs, Spinraza, other drugs deemed by BMS as appropriate for FFS coverage, and Hepatitis-C virus-related drugs will be covered by FFS Medicaid. Drugs and supplies dispensed by a physician, acquired by the physician at no cost, are not covered by Medicaid. BMS will provide the MCO with pharmacy utilization data to support coordination of care for the enrollee. The MCO remains responsible for all physician administered drugs, such as those provided as part of an inpatient stay, a bundled ER visit, or administered vaccinations. The MCO is permitted to negotiate and collect supplemental rebates with drug companies for provider-administered drugs. The MCO’s provision for physician discretion and the medical needs of the patient must not be impaired by rebate agreements. The rebate amount shall be accounted for in the MLR calculation. The MCO shall comply with Section 1004 of the SUPPORT for Patients and Communities Act and the Drug Utilization Review (DUR) regulations as described in section 1927(g) of the Act and 42 CFR part §456, subpart K. The MCO shall be subject to both prospective and retrospective requirements, as applicable, dependent on whether the medication is administered via point of sale or clinically. The MCO must comply with all established criteria required by WV Medicaid before approving the initial coverage of any physician administered agent which is currently available in a point- of-sale form. If exceptions to the criteria are considered appropriate or necessary, the MCO must obtain written consent for such variance from BMS Office of Pharmacy Services. The MCO shall be subject to following provisions of Section 1004 of the SUPPORT for Patient and Communities Act:

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age twenty-one (21), and prenatal vitamins) are covered by FFS Medicaid. Hemophilia-related clotting factor drugs, Spinraza, other drugs deemed by BMS DHHR as appropriate for FFS coverage, and Hepatitis-C virus-related drugs will be covered by FFS Medicaid. Drugs and supplies dispensed by a physician, acquired by the physician at no cost, are not covered by Medicaid. BMS The Department will provide the MCO with pharmacy utilization data to support coordination of care for the enrollee. The MCO remains responsible for all physician other provider-administered drugs, such as those provided as part of an inpatient stay, a bundled ER visit, or administered vaccinations. The MCO is permitted to negotiate and collect supplemental rebates with drug companies for provider-provider- administered drugs. The MCO’s provision for physician discretion and the medical needs of the patient must not be impaired by rebate agreements. The rebate amount shall be accounted for in the MLR calculation. The MCO shall comply with Section 1004 of the SUPPORT for Patients and Communities Act and the Drug Utilization Review (DUR) regulations as described in section 1927(g) of the Act and 42 CFR part §456, subpart K. The MCO shall be subject to both prospective and retrospective requirements, as applicable, dependent on whether the medication is administered via point of sale or clinically. The MCO must comply with all established criteria required by WV Medicaid before approving the initial coverage of any physician physician-administered agent which is currently available in a point- of-sale form. If exceptions to the criteria are considered appropriate or necessary, the MCO must obtain written consent for such variance from BMS Office of Pharmacy Services. The MCO shall be subject to following provisions of Section 1004 of the SUPPORT for Patient and Communities Act:

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age twenty-one (21), and prenatal vitamins) are covered by FFS Medicaid/WVCHIP. Hemophilia-related clotting factor drugs, Spinraza, other drugs deemed by BMS as appropriate for FFS coverage, and Hepatitis-C virus-related drugs will be covered by FFS Medicaid/WVCHIP. Drugs and supplies dispensed by a physician, acquired by the physician at no cost, are not covered by MedicaidMedicaid and WVCHIP. BMS will provide the MCO with pharmacy utilization data to support coordination of care for the enrollee. The MCO remains responsible for all physician administered drugs, such as those provided as part of an inpatient stay, a bundled ER visit, or administered vaccinations. The MCO is permitted to negotiate and collect supplemental rebates with drug companies for provider-administered drugs. The MCO’s provision for physician discretion and the medical needs of the patient must not be impaired by rebate agreements. The rebate amount shall be accounted for in the MLR calculation. The MCO shall comply with Section 1004 of the SUPPORT for Patients and Communities Act and the Drug Utilization Review (DUR) regulations as described in section 1927(g) of the Act and 42 CFR part §456, subpart K. The MCO shall be subject to both prospective and retrospective requirements, as applicable, dependent on whether the medication is administered via point of sale or clinically. The MCO must comply with all established criteria required by WV Medicaid BMS before approving the initial coverage of any physician administered agent which is currently available in a point- point-of-sale form. If exceptions to the criteria are considered appropriate or necessary, the MCO must obtain written consent for such variance from BMS Office of Pharmacy Services. The MCO shall be subject to following provisions of Section 1004 of the SUPPORT for Patient and Communities Act:

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age twenty-one (21), and prenatal vitamins) are covered by FFS Medicaid. Hemophilia-related clotting factor drugs, Spinraza, other drugs deemed by BMS as appropriate for FFS coverage, and Hepatitis-C virus-related drugs will be covered by FFS Medicaid. Drugs and supplies dispensed by a physician, acquired by the physician at no cost, are not covered by Medicaid. BMS will provide the MCO with pharmacy utilization data to support coordination of care for the enrollee. The MCO remains responsible for all physician physician-administered drugs, such as those provided as part of an inpatient stay, a bundled ER visit, or administered vaccinations. The MCO is permitted to negotiate and collect supplemental rebates with drug companies for provider-administered drugs. The MCO’s provision for physician discretion and the medical needs of the patient must not be impaired by rebate agreements. The rebate amount shall be accounted for in the MLR calculation. The MCO shall comply with Section 1004 of the SUPPORT for Patients and Communities Act and the Drug Utilization Review (DUR) regulations as described in section 1927(g) of the Act and 42 CFR part §456, subpart K. The MCO shall be subject to both prospective and retrospective requirements, as applicable, dependent on whether the medication is administered via point of sale or clinically. The MCO must comply with all established criteria required by WV Medicaid before approving the initial coverage of any physician physician-administered agent which is currently available in a point- of-point of sale form. If exceptions to the criteria are considered appropriate or necessary, the MCO must obtain written consent for such variance from BMS Office of Pharmacy Services. The MCO shall be subject to following provisions of Section 1004 of the SUPPORT for Patient and Communities Act:

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age twenty-one (21), and prenatal vitamins) are covered by FFS Medicaid. Hemophilia-related clotting factor drugs, Spinraza, other drugs deemed by BMS as appropriate for FFS coverage, and Hepatitis-C virus-related drugs will be covered by FFS Medicaid. Drugs and supplies dispensed by a physician, acquired by the physician at no cost, are not covered by Medicaid. BMS will provide the MCO with pharmacy utilization data to support coordination of care for the enrollee. The MCO remains responsible for all physician physician-administered drugs, such as those provided as part of an inpatient stay, a bundled ER visit, or administered vaccinations. The MCO is permitted to negotiate and collect supplemental rebates with drug companies for provider-provider- administered drugs. The MCO’s provision for physician discretion and the medical needs of the patient must not be impaired by rebate agreements. The rebate amount shall be accounted for in the MLR calculation. The MCO shall comply with Section 1004 of the SUPPORT for Patients and Communities Act and the Drug Utilization Review (DUR) regulations as described in section 1927(g) of the Act and 42 CFR part §456, subpart K. The MCO shall be subject to both prospective and retrospective requirements, as applicable, dependent on whether the medication is administered via point of sale or clinically. The MCO must comply with all established criteria required by WV Medicaid before approving the initial coverage of any physician physician-administered agent which is currently available in a point- of-point of sale form. If exceptions to the criteria are considered appropriate or necessary, the MCO must obtain written consent for such variance from BMS Office of Pharmacy Services. The MCO shall be subject to following provisions of Section 1004 of the SUPPORT for Patient and Communities Act:: Claim Reviews: Retrospective reviews on opioid prescriptions exceeding state defined limitations on an ongoing basis. Retrospective reviews on concurrent utilization of opioids and benzodiazepines as well as opioids and antipsychotics on an ongoing periodic basis. Programs to monitor antipsychotic medications to children: Antipsychotic agents are reviewed for appropriateness for all children including xxxxxx children based on approved indications and clinical guidelines. Fraud and abuse identification: The DUR program has established a process that identifies potential fraud or abuse of controlled substances by enrolled individuals, health care providers and pharmacies.