Common use of Pharmacy Access Clause in Contracts

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 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. Note: MCOs may request exceptions to these requirements on a case-by-case basis. Mail order pharmacies, including specialty pharmacies that only mail prescriptions, will not be included when calculating these percentages. However, MCOs will be required to report on the number of prescriptions filled and number of clients served through mail order/specialty pharmacies by MCO Program and Service Area. 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. 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 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. Note: MCOs may request exceptions to these requirements on a case-by-case basis. Mail order pharmacies, including specialty pharmacies that only mail prescriptions, will not be included when calculating these percentages. However, MCOs will be required to report on the number of prescriptions filled and number of clients served through mail order/specialty pharmacies by MCO Program and Service Area. Nursing Facility Access: Effective September 1, 2014, STAR+PLUS MCOs must ensure that Members have access to a Nursing Facility in the Provider Network within 75 miles of the Member’s residence. 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. 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 ’s residence, and access to at least one (1) pharmacy with 24-hour coverage within 75 miles of the Member's ’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 standardsstandards apply. 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 two (2) miles of the Member's ’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 ’s residence; and • 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 ’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 two (2) miles of the Member's Members’ residence; • In suburban counties, at least 75 percent of Members must have access to a Network Pharmacy within 5 five (5) miles of the Member's ’s residence; and • 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 ’s residence. Note: MCOs may request exceptions to these requirements on a case-by-case basis. Mail order pharmacies, including specialty pharmacies that only mail prescriptions, will not be included when calculating these percentages. However, MCOs will be required to report on the number of prescriptions filled and number of clients served through mail order/specialty pharmacies by MCO Program and Service Area. All other Covered Services, except for services provided in the Member's ’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 ’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 ’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. 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 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. Note: MCOs may request exceptions to these requirements on a case-by-case basis. Mail order pharmacies, including specialty pharmacies that only mail prescriptions, will not be included when calculating these percentages. However, MCOs will be required to report on the number of prescriptions filled and number of clients served through mail order/specialty pharmacies by MCO Program and Service Area. Nursing Facility Access: Effective March 1, 2015, STAR+PLUS MCOs must ensure that Members have access to a Nursing Facility in the Provider Network within 75 miles of the Member’s residence. 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. 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 two (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; and • 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 two (2) miles of the Member's Members' residence; • In suburban counties, at least 75 percent of Members must have access to a Network Pharmacy within 5 five (5) miles of the Member's residence; and • 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. Note: MCOs may request exceptions to these requirements on a case-by-case basis. Mail order pharmacies, including specialty pharmacies that only mail prescriptions, will not be included when calculating these percentages. However, MCOs will be required to report on the number of prescriptions filled and number of clients served through mail order/specialty pharmacies by MCO Program and Service Area. 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.