Pharmacy Access. Effective March 1, 2012, the MCO must meet the following minimum requirements. The MCO must ensure that all Members have access to at least one (1) Network Pharmacy within 15 miles of the Member's residence, and access to at least one (1) pharmacy with 24-hour coverage within 75 miles of the Member's residence. MCOs may request exceptions to this requirement on a case-by-case basis. Effective September 1, 2012, HHSC will apply additional benchmark performance standards. For purposes of this requirement only, the terms urban, suburban, and rural counties have the following meaning: Urban - Counties that have been designated as metropolitan by the Office of Management and Budget (OMB), and that contain the most populated city within a metropolitan area, also known as Metropolitan Statistical Area. HHSC Strategic Decision Support (SDS) classifies these counties as Metro Central City counties. A county meets the definition of metropolitan if it has a central city, or pair of twin cities in it, with a minimum population of 50,000. Suburban - Counties that have been designated as metropolitan by the OMB, and that are adjacent (share a boundary) to a Metro Central City county. The SDS classifies these counties as Metro Suburban counties. Rural - Non-metropolitan counties of the state, regardless of whether they are adjacent or non-adjacent to a metropolitan county. For counties included in the Medicaid Rural Service Area, the following standard applies to STAR effective September 1, 2012: • In urban counties, at least 75 percent of Members must have access to a Network Pharmacy within 2 miles of the Member's residence; • In suburban counties, at least 55 percent of Members must have access to a Network Pharmacy within 5 miles of the Member's residence; • In rural counties, at least 90 percent of Members must have access to a Network Pharmacy within 15 miles of the Member's residence; and • In urban, suburban, and rural counties, at least 90 percent of Members must have access to a 24-hour pharmacy within 75 miles of the Member's residence. For all other counties and Programs, the following standard applies effective September 1, 2012: • In urban counties, at least 80 percent of Members must have access to a Network Pharmacy within 2 miles of the Member's residence; • In suburban counties, at least 75 percent of Members must have access to a Network Pharmacy within 5 miles of the Member's residence; • In rural counties, at least 90 percent of Members must have acc...
Pharmacy Access. Contractor shall ensure an Enrollee has access to at least one (1) pharmacy within a fifteen (15)–mile radius of or fifteen (15)–minute drive from the Enrollee’s residence. If an Enrollee lives in a Rural Area, the Enrollee shall have access to at least one (1) pharmacy within a sixty (60)–mile radius of or sixty (60)–minute drive from his or her residence.
Pharmacy Access. At a minimum, the MCO must ensure that all Members have access to at least one (1) Network Pharmacy within 15 miles of the Member’s residence, and access to at least one (1) pharmacy with 24-hour coverage within 75 miles of the Member’s residence. MCOs may request exceptions to this requirement on a case-by-case basis. All other Covered Services, except for services provided in the Member’s residence: At a minimum, the MCO must ensure that all Members have access to at least one (1) Network Provider for each of the remaining Covered Services described in Attachments B-2, “STAR Covered Services,” B-2.1 “CHIP Covered Services,” and B-2.2, “STAR+PLUS Covered Services,” within 75 miles of the Member’s residence. This access requirement includes, but is not limited to, specialists, specialty Hospitals, psychiatric Hospitals, diagnostic and therapeutic services, and single or limited service health care physicians or Providers, as applicable to the MCO Program. The MCO is not precluded from making arrangements with physicians or providers outside the MCO’s Service Area for Members to receive a higher level of skill or specialty than the level available within the Service Area, including but not limited to, treatment of cancer, xxxxx, and cardiac diseases. HHSC may consider exceptions to the above access-related requirements when an MCO has established, through utilization data provided to HHSC, that a normal pattern for securing Health Care Services within an area does not meet these standards, or when an MCO is providing care of a higher skill level or specialty than the level which is available within the Service Area.
Pharmacy Access. For purposes of this section, "prescription" shall include authorization for legend and over-the-counter drugs covered by Medicaid policy.
a. The MCO shall be responsible for payment for pharmacy services regardless of a Member's diagnosis. The only exception is that the CT BHP shall be responsible for methadone costs that are part of the bundled reimbursement for methadone maintenance and ambulatory detox providers. Prescribing behavioral health providers participating in the CT BHP will follow the applicable pharmacy program requirements, including the formulary, of the MCO. These providers will provide the MCO with any clinical information needed to support requests for authorization or the preparation of summaries for administrative hearings. The MCO shall promptly inform the DEPARTMENT of any changes to its pharmacy program requirements.
b. Pharmacies must be available and accessible on a statewide basis. The MCO shall:
1. Maintain a comprehensive provider network of pharmacies that will, within available resources, assure twenty four (24) hour access to pharmaceutical goods and services;
2. The MCO may establish a pharmacy lock-in program for Members suspected of abuse or excessive utilization. Any MCO pharmacy lock-in program will be subject to DEPARTMENT approval;
3. Have established protocols to respond to urgent requests for medications;
4. Monitor and take steps to correct excessive utilization of regulated substances, including but not limited to, restricting pharmacy access pursuant to a pharmacy lock-in program approved by the DEPARTMENT; and
5. Require pharmacists to utilize the Automated Eligibility Verification System (AEVS) to determine client eligibility and MCO affiliation when there is a discrepancy between the information in the MCO's eligibility system and information given to the pharmacists by the Member, the Member's physician or other third party.
c. The MCO shall require that its provider network of pharmacies offer medically necessary goods and services to the MCO's Members.
d. The MCO may have a drug management program that includes a prescription drug formulary.
1. The MCO drug formulary must include only Food and Drug Administration approved drug products and must be broad enough in scope to meet the needs of all Members.
2. For each specific therapeutic drug class the MCO drug formulary shall consist of a reasonable selection of drugs that do not require prior approval.
e. The MCO shall obtain the DEPARTMENT'S written appro...
Pharmacy Access. For purposes of this section, "prescription" shall include authorization for legend and over-the-counter drugs covered by Medicaid policy.
a. Pharmacies must be available and accessible on a statewide basis. The MCO shall:
Pharmacy Access. 8.2.1 The Customer shall not access or use the Pharmacy Access Solution for the purposes of operating a distance selling chemist operation, being a pharmacy business which provides pharmaceutical services from distance selling premises (as defined in the NHS (Pharmaceutical Services) Regulations 2012).
8.2.2 The Customer shall ensure that only persons with defined roles (including, the pharmacist(s)) are permitted to access the Pharmacy Access Solution.
8.2.3 The Customer shall notify EHCP as to the identity of any “Participating Practices” (being a GP practice using a compatible clinical system which has consented to participate in the delivery of the Pharmacy Access services) so that EHCP may endeavour to arrange for the relevant clinical system to be configured so as to enable the Pharmacy Access Solution.
8.2.4 The Customer acknowledges that EHCP shall not be responsible for:
8.2.4.1 securing the consent of any GP practice to enable the Pharmacy Access Solution;
8.2.4.2 the accuracy, completeness or suitability of data submitted by a Participating Practice to the Customer; or
8.2.4.3 supervising the adequacy of data submitted to the Participating Practices by the Customer and any impact this may have on their ability to request repeat prescriptions.
8.2.5 The Customer shall ensure that at all times throughout the Term it remains compliant with the NHS Information Governance Toolkit in order to use the GP Record Viewer capability within the Pharmacy Access Solution.
8.2.6 The Customer acknowledges that in relation to the Medicines Manager and GP Record Viewer elements of the Pharmacy Access Solution that the relevant Participating Practices would be Data Controllers and that EHCP where acting as a Data Processor on their behalf would be required to comply with the lawful instructions of the relevant Participating Practice. Therefore, EHCP is entitled to immediately restrict the Customer’s access to any Personal Data if instructed to do so by the relevant Participating Practice. The Customer acknowledges that EHCP is not responsible for, and cannot, maintain the consent of the Participating Practices to allow the relevant Services to be provided to the Customer, and as a result EHCP shall in no way be liable in the event that a Participating Practice withdraws such consent.
8.2.7 The Customer shall ensure that it has appropriate consent from each patient before viewing such person's medical record(s), and should the Customer fail to obtain such consent t...
Pharmacy Access a. The MCO shall be responsible for payment for pharmacy services and all associated charges, regardless of a Member's diagnosis. The only exception is that the Partnership shall be responsible for methadone costs that are part of the bundled reimbursement for methadone maintenance and ambulatory detox providers. Prescribing behavioral health providers participating in the Partnership will follow the applicable pharmacy program requirements, including the formulary, of the MCO. These providers will provide the MCO with any clinical information needed to support requests for authorization or the preparation of summaries for administrative hearings. The MCO shall promptly inform the Department of any changes to its pharmacy program requirements.
b. Pharmacies must be available and accessible on a statewide basis. The MCO shall:
1. Maintain a comprehensive provider network of pharmacies that will within available resources assure twenty-four (24) hour access to a full range of pharmaceutical goods and services;
2. Have established protocols to respond to urgent requests for medications;
3. Monitor and take steps to correct excessive utilization of regulated substances;
4. Have established protocols in place to assure the timely provision of pharmacy goods and to determine client eligibility and MCO affiliation services (by contacting the DEPARTMENT or its agent via telephone or fax) when there is a discrepancy between the information in the MCO's eligibility system and information given to the pharmacists by the Member, the Member's physician or other third party; and
5. Monitor quality assurance measures to assure that Member abuse of pharmacy benefits is corrected in a timely fashion.
