Pharmacy. Pharmacy hereby represents that neither Pharmacy, nor, to the best of Pharmacy’s knowledge, Pharmacist, Pharmacy’s employees, agents or independent
Pharmacy. Prescription drugs are a benefit under the Hoosier Healthwise program to be covered by the Contractor. The Contractor shall support FSSA in promptly responding to public and legislative inquiries involving the design and management of the Contractor’s pharmacy benefit. If the Contractor elects to subcontract with a PBM, the Contractor shall ensure compliance with all subcontracting requirements outlined in Section 2.7, including but not limited to conducting regular audits and monitoring of the subcontractor’s data and performance, as well as requiring their PBM to conduct regular audits of their pharmacy provider networks. The Contractor shall not be responsible for member pharmacy claims incurred prior to the effective date of this contract. The Contractor shall provide a proposal which considers a common or “unified” preferred drug list (PDL) for the pharmacy benefit. Unification of the PDL would include prior authorization (PA), step edit and utilization edit criteria. The Contractor shall, at the direction of the Secretary, implement specified fee-for-service PDL and/or prior authorization, if unified PDL is not implemented. The Contractor shall develop an escalation process for specified unique review processes and requests submitted by state or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non- IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non- IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The contractor shall ensure that at all times during the term of this contract its pharmacy benefit fully complies with applicable provisions of IC 12-15-35 and IC 12-15-35.5.
Pharmacy. Pharmacy hereby represents that neither Pharmacy, nor, to the best Pharmacy’s knowledge, Pharmacist, Pharmacy’s employees, agents or independent contractors involved in the provision of services have been excluded from participation in any Federally-funded health care programs, including, but not limited to, Medicare and Medicaid.
Pharmacy a pharmacy which is either under control of Institution (Institutional Pharmacy) or designated by Institution or Investigator to provide its services in connection with the Study.
Pharmacy. The Contractor must establish policies and procedures to comply with the Division’s Prior Authorization criteria in accordance with the PDL guidance for the drugs listed on the PDL. Drugs with manual prior authorization criteria are developed and maintained by the Division and can be found on the Division’s website. When changes occur to these criteria, the Division will notify the Contractor. Updated criteria must be implemented upon receipt. Drugs with electronic prior authorization criteria (Smart PA) are addressed in Section 0.X.Xxxx Exchange Requirements, of this Contract. The Contractor may approve non-preferred drugs when one of the following Prior Authorization criteria is satisfied:
a. Member experiences an adverse event(s) or reaction(s) to preferred medications; or
b. Contraindications to preferred medications (i.e. drug interaction, existing medical condition preventing the use of preferred medications).
c. The Contractor must establish criteria and coverage policies for drugs not listed on the PDL, which must be approved by the Division. The Contractor must ensure that decisions regarding policies and procedures for prescription drugs are made in a clinically sound manner. The Division allows pharmacy providers thirty (30) calendar days to submit a request for reconsideration after receipt of a Prior Authorization denial. The Contractor and its Subcontractor or delegated vendors shall adhere to this time frame.
Pharmacy. The Contractor must establish policies and procedures to comply with the Division’s Prior Authorization criteria in accordance with the PDL guidance for the drugs listed on the PDL. The Contractor may approve non-preferred drugs when one of the following Prior Authorization criteria is satisfied:
a. Member experiences an adverse event(s) or reaction(s) to preferred medications; or
b. Contraindications to preferred medications (i.e. drug interaction, existing medical condition preventing the use of preferred medications).
c. The Contractor must establish criteria and coverage policies for drugs not listed on the PDL, which must be approved by the Division. The Contractor must ensure that decisions regarding policies and procedures for prescription drugs are made in a clinically sound manner.
Pharmacy i. Generic first across all plans: The member/dependent(s) will be required to use generic medication first. The member/dependent(s) will be offered to use brand-name drugs only after first trying similar generic medications and the generic medication has not been effective in treating member’s/dependent(s) condition. If brand-name medication is required, the member/dependent(s) will be responsible for the difference in cost of the generic medication versus the brand medication.
ii. Mail-Order/90-Day Limited Network Retail Pharmacy Solution for maintenance/preventive drugs: The member/dependent(s) will be required to use mail order or pick up prescriptions at an in-network retail pharmacy for all maintenance/preventive drugs needed for a long-term health condition. First time prescription will only be filled at retail pharmacy three (3) times and subsequent refills would be filled using mail order pharmacy or an in-network 90 day retail pharmacy. The member/dependent(s) will pay only two (2) copays for a 90 day refill of mail order or a limited network 90-day retail pharmacy for prescriptions.
Pharmacy. 4.6.6.1 The Contractor shall provide pharmacy services either directly or through a Pharmacy Benefits Manager (PBM). The Contractor or its PBM may establish a drug formulary if the following minimum requirements are met: · Drugs from each specific therapeutic drug class are included and are sufficient in amount, duration, and scope to meet Members’ medical needs; · The only excluded drug categories are those permitted under section 1927(d) of the Social Security Act; · A Pharmacy & Therapeutics Committee that advises and/or recommends formulary decisions; and · Over-the-counter medications specified in the Georgia State Medicaid Plan are included in the formulary.
4.6.6.2 The Contractor shall provide the formulary to DCH upon the request of DCH.
4.6.6.3 If the Contractor chooses to implement a mail-order pharmacy program, any such program must be accordance with State and federal law.
Pharmacy. If the Health Plan elects to use a more restrictive pharmacy network than the non-Medicaid Reform Fee-for-Service network, the Health Plan shall provide at least one (1) licensed pharmacy per 2,500 Enrollees. The Health Plan shall ensure that its contracted pharmacies comply with the Settlement Agreement to Xxxxxxxxx, et al. x. Xxxxxx (case number 02-20964 Civ-Gold/ Xxxxxxxx) (HSA).
Pharmacy. Prescription drugs are a benefit under the Hoosier Healthwise program to be covered by the Contractor. The Contractor shall support FSSA in promptly responding to public and legislative inquiries involving the design and management of the Contractor’s pharmacy benefit. If the Contractor elects to subcontract with a PBM, the Contractor shall ensure compliance with all subcontracting requirements outlined in Section 2.7, including but not limited to conducting regular audits and monitoring of the subcontractor’s data and performance, as well as requiring their PBM to conduct regular audits of their pharmacy provider networks. The Contractor shall not be responsible for member pharmacy claims incurred prior to the effective date of this contract. The Contractor shall provide a proposal which considers a common or “unified” preferred drug list (PDL) for the pharmacy benefit. Unification of the PDL would include prior authorization (PA), step edit, and utilization edit criteria. The Contractor shall, at the direction of the Secretary, implement specified fee-for-service PDL and/or prior authorization, if unified PDL is not implemented. The Contractor shall develop an escalation process for specified unique review processes and requests submitted by state or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. 2 For CHIP, coverage of treatment services is limited to the Package C benefit package coverage limitations.
