Pharmacy Prior Authorizations Sample Clauses

Pharmacy Prior Authorizations. 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 not promote adherence to a PDL or preferred drug program other than that which has been approved by the Division. The Contractor may approve drugs outside of the PDL when one of the following Prior Authorization criteria is satisfied: a. Member must have used the preferred agents for at least a thirty (30) calendar day course of treatment per drug and failed trials within six (6) months prior to requesting the Prior Authorization and there is documentation of therapeutic failure of preferred drugs; or b. Adverse event(s) reaction(s) to preferred medications; or c. Contraindications to preferred medications (i.e. drug interaction, existing medical condition preventing the use of preferred medications). 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’s Office of Pharmacy’s approval is required for all Clinical Edit policies. The Division must receive this criteria and coverage policies for advanced written approval forty-five (45) calendar days prior to implementation.
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Pharmacy Prior Authorizations. The Contractor shall conduct a Prior Authorization (PA) program that complies with the requirements of section 1927(d)(5) of the Social Security Act and with Department requirements, as if such requirements apply to the Contractor instead of the Department. The Contractor’s PA program shall ensure there is no undue disruption of a Member’s access to care; shall prevent penalization of the Provider or Member, financially or otherwise, for such PA requests or approvals; and shall incorporate the minimum requirements described herein: A. Clinical PA review criteria shall be aligned with FDA approved indications, best clinical practice standards, and/or other national standards. B. A physician peer review shall be available upon a Provider’s request for any denial made at a pharmacist review level. C. PA determinations including those from escalated reviews shall be made and communicated to the requesting provider within twenty- four (24) hours from the initial request including weekends in compliance with the provisions of OBRA 1990 mandate, Section 1927 of the Social Security Act, and other federal regulations. D. All PA activities and decisions shall be documented in Contractor’s online pharmacy case management system. This information shall be available for immediate review at the Department’s request or other timeframe as specified by the Department. E. In the event a prescription is for a drug awaiting PA and the pharmacy cannot reach the prescribing physician, and when the dispensing pharmacist using reasonable clinical judgment deems it necessary to avoid imminent harm or injury to the Member, a seventy-two (72) hour emergency supply shall be provided. If the physician prescribed an amount of drug that is less than a seventy- two (72) hour supply but is packaged so that it must be dispensed intact, the pharmacist may dispense the packaged drug and Contractor shall pay for this quantity even if it exceeds a calculated seventy-two (72) hour supply. Contractor shall instruct the pharmacy providers how to perform the override in the NCPDP environment of the POS pharmacy claims processing system. F. Contractor’s PA process shall include procedures for Member appeals and grievances submitted by the Member or the prescriber authorized to act on behalf of the Member related to PAs denied after the final escalated review. Contractor’s procedures for PA related appeals and grievances shall be in accordance with Section 25.2 Member Grievance and Appeal Policies a...
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Pharmacy Prior Authorizations. The Contractor agrees that during the first 90 days of an enrollment that the Department’s Fee- For-Service prior authorization for pharmacy services or a prior authorization which has been issued by another Health Plan to an Enrollee in the Contractor’s Health Plan for pharmacy services will be honored for at least one temporary 30 day fill unless the prescription is written for less than 30 days by the prescriber.
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Related to Pharmacy Prior Authorizations

  • Prior Authorization A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.

  • Governmental Authorizations; Private Authorizations; Governmental Filings The Borrower has obtained, maintained and kept in full force and effect all Governmental Authorizations and Private Authorizations which are necessary for it to properly carry out its business, except where the failure to do so could not reasonably be expected to have a Material Adverse Effect, and made all material Governmental Filings necessary for the execution and delivery by it of the Facility Documents to which it is a party, the Borrowings by the Borrower under this Agreement, the pledge of the Collateral by the Borrower under this Agreement and the performance by the Borrower of its obligations under this Agreement, the other Facility Documents, and no material Governmental Authorization, Private Authorization or Governmental Filing which has not been obtained or made, is required to be obtained or made by it in connection with the execution and delivery by it of any Facility Document to which it is a party, the Borrowings by the Borrower under this Agreement, the pledge of the Collateral by the Borrower under this Agreement or the performance of its obligations under this Agreement and the other Facility Documents to which it is a party.

  • Power; Authorization Such Investor has all requisite power and authority to execute and deliver this Agreement. This Agreement, when executed and delivered by such Investor, will constitute a valid and legally binding obligation of such Investor, enforceable in accordance with its respective terms, except as: (a) limited by applicable bankruptcy, insolvency, reorganization, moratorium and other laws of general application affecting enforcement of creditors’ rights generally; and (b) limited by laws relating to the availability of specific performance, injunctive relief or other equitable remedies.

  • Permits, Authorizations, Etc Buyers shall have obtained ----------------------------- any and all material permits, authorizations, consents, waivers and approvals required for the lawful consummation of the Merger.

  • Government Authorizations Section 1.1 (a) of the Disclosure Schedule contains a true and complete list of all the Licenses, which Licenses are sufficient for the lawful conduct of the business and operation of the Station in the manner and to the full extent they are currently conducted. Seller is the authorized legal holder of the Licenses, none of which is subject to any restriction or condition which would limit in any material respect the full operation of the Station as now operated. There are no applications, complaints or proceedings pending or, to the best of Seller's knowledge, threatened as of the date hereof before the Commission or any other governmental authority relating to the business or operations of the Station, other than applications, complaints or proceedings which generally affect the broadcasting industry as a whole, and other than reports and forms filed in the ordinary course of the Station's business. Seller has delivered to Buyer true and complete copies of the Licenses, including any and all additions, amendments and other modifications thereto. The Licenses are in good standing, are in full force and effect and are unimpaired by any act or omission of Seller or its officers, directors or employees; and the operation of the Station is in accordance with the Licenses and the underlying construction permits. No proceedings are pending or, to the knowledge of Seller, are threatened which may result in the revocation, modification, non-renewal or suspension of any of the Licenses, the denial of any pending applications, the issuance of any cease and desist order, the imposition of any administrative actions by the Commission with respect to the Licenses or which may affect Buyer's ability to continue to operate the Station as it is currently operated. Seller has taken no action which, to its knowledge, could lead to revocation or non- renewal of the Licenses, nor omitted to take any action which, by reason of its omission, could lead to revocation of the Licenses. All material reports, forms and statements required to be filed with the Commission with respect to the Station since the grant of the last renewal of the Licenses have been filed and are complete and accurate. To the knowledge of Seller, there are no facts which, under the Communications Act of 1934, as amended, or the existing rules, regulations, requirements, policies and orders of the Commission, would disqualify Seller as assignor, and Buyer as assignee, in connection with the Assignment Application.

  • Required Authorizations There is no requirement to make any filing with, give any notice to, or obtain any Authorization of, any Governmental Entity as a condition to the lawful completion of the transactions contemplated by this Agreement.

  • Governmental Authorizations and Consents Each Credit Party shall have obtained all Governmental Authorizations and all consents of other Persons, in each case that are necessary or advisable in connection with the transactions contemplated by the Credit Documents and each of the foregoing shall be in full force and effect and in form and substance reasonably satisfactory to Administrative Agent. All applicable waiting periods shall have expired without any action being taken or threatened by any competent authority which would restrain, prevent or otherwise impose adverse conditions on the transactions contemplated by the Credit Documents or the financing thereof and no action, request for stay, petition for review or rehearing, reconsideration, or appeal with respect to any of the foregoing shall be pending, and the time for any applicable agency to take action to set aside its consent on its own motion shall have expired.

  • LICENSES; CERTIFICATIONS; AUTHORIZATIONS; & APPROVALS Contractor represents and warrants that Contractor possesses and shall keep current during the term of this Contract all required licenses, certifications, permits, authorizations, and approvals necessary for Contractor’s proper performance of this Contract.

  • Governmental Authorization; Third Party Consents No approval, consent, compliance, exemption or authorization of any governmental authority or agency, or of any other person or entity, is necessary or required in connection with the execution, delivery or performance by, or enforcement against, the Warrant Holder of this Warrant Agreement or the transactions contemplated hereby.

  • Authorization; Approvals The issuance of the Policy and the execution, delivery and performance of this Agreement and the Insurance Agreement have been duly authorized by all necessary corporate proceedings. No further approvals or filings of any kind, including, without limitation, any further approvals of or further filings with any governmental agency or other governmental authority, or any approval of the Insurer’s board of directors or stockholders, are necessary for the Policy, this Agreement and the Insurance Agreement to constitute the legal, valid and binding obligations of the Insurer.

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