Pharmacy Services. The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.
Pharmacy Services. The Contractor agrees to comply with the requirements regarding covered pharmacy and over-the- counter (OTC) benefits. The Contractor will comply with the EOHHS Pharmacy Home Program and the Generics First Initiative, including the maintenance of the drug formulary in accordance with the direction of the EOHHS Pharmacy Committee.
Pharmacy Services. The PH-MCO must comply with the Department’s outpatient drug services standards and requirements described in Exhibit BBB, Outpatient Drug Services.
Pharmacy Services. 5.30.24.4.1 Number of KOPs issued during month. 5.30.24.4.2 Number of prescriptions issued during month. 5.30.24.4.3 Number of psychotropic medications prescribed during month. 5.30.24.4.4 Number of Class III drugs issued during month.
Pharmacy Services. Except as provided in Section 2.6.1.3 of this Agreement, pharmacy services shall not be provided by the CONTRACTOR but shall be provided by a pharmacy benefits manager (PBM) under contract with TENNCARE. Coverage of pharmacy services is described in TennCare rules and regulations. TENNCARE does not cover pharmacy services for enrollees who are dually eligible for TennCare and Medicare.
Pharmacy Services. CONTRACTOR shall provide sufficient controls over both its contracted and employed physicians/psychiatrists to be able to ensure strict adherence to the FDC’s drug formulary. Compliance with the FDC’s DER policy is required with one exception, an appropriately qualified CONTRACTOR representative shall stand in place of FDC to review and approve or deny DER, prior to prescribing any non-formulary medications. Subsets or restricted use of the FDC’s formulary that effectively limit, in any manner, the use of the FDC’s formulary are prohibited. Additionally, all medications shall be prescribed appropriately as indicated in the current edition of Drug Facts and Comparisons and the most recent Physicians’ Desk Reference. CONTRACTOR shall not prescribe non-therapeutic doses, or change, increase or decrease medication or dosages without providing ample time for the medication to take effect as provided for in the package insert. If this occurs, CONTRACTOR shall be considered non-compliant with the provisions of care in the Contract. Should there be a requirement for use of a non-therapeutic dosage or the need to prematurely change medication or dosages, there must be appropriate clinical justification documented in the chart as well as adherence to the DER process to gain approval. Practitioners’ prescribing practices shall be tracked monthly and reported by CONTRACTOR. Prescribing practices shall also be monitored for performance measure compliance.
Pharmacy Services. Provider shall coordinate with the TennCare pharmacy benefits manager (PBM) regarding authorization and payment for pharmacy services.
Pharmacy Services. The MCO must provide pharmacy-dispensed prescriptions as a Covered Service. The MCO must submit pharmacy clinical guidelines and prior authorization policies and for review and approval during Readiness Review, then after the Operational Start Date prior to any changes. In determining whether to approve these materials, HHSC will review factors such as the clinical efficacy and Members' needs. The MCO must allow pharmacies to fill prescriptions for covered drugs ordered by any licensed provider regardless of Network participation and must encourage Network pharmacies to also become Medicaid-enrolled durable medical equipment (DME) providers. The MCO is responsible for negotiating reasonable pharmacy provider reimbursement rates, including individual MCO maximum allowable cost (MAC) rates, as described in Section 8.1.21.11, "Maximum Allowable Cost Requirements." The MCO must ensure that, as an aggregate, rates comply with 42 C.F.R. Part 50, Subpart E, regarding upper payment limits.
Pharmacy Services. The MCO must provide pharmacy-dispensed prescriptions as a Covered Service. The MCO must allow Members access to prescribed drugs though formularies and a preferred drug list (PDL) developed by HHSC. HHSC will maintain separate Medicaid and CHIP formularies, and a Medicaid PDL. The MCO must administer the PDL in a way that allows access to all non-preferred drugs that are on the formulary through a structured prior authorization process. The following information must be submitted to HHSC for review and approval during Readiness Review, then after the Operational Start Date prior to any changes: pharmacy clinical guidelines; and prior authorization policies and procedures. In determining whether to approve these materials, HHSC will review factors such as the clinical efficacy and Members’ needs. The MCO may include mail-order pharmacies in their Networks, but must not require Members to use them. Members who opt to use this service may not be charged fees, including postage and handling fees. In Medicaid fee-for-service, the Vendor Drug Program pays qualified community retail pharmacies for pharmaceutical delivery services. The MCO must implement a process to ensure that Medicaid and CHIP Members receive free outpatient pharmaceutical deliveries from community retail pharmacies in their Service Areas, or through other methods approved by HHSC. Mail order delivery is not an appropriate substitute for delivery from a qualified community retail pharmacy unless requested by the Member. The MCO’s process must be approved by HHSC, submitted using HHSC’s template, and include all qualified community retail pharmacies identified by HHSC. HHSC will provide the MCO daily formulary and PDL files. The MCO must update its formulary and PDL files, or ensure that its Pharmacy Benefits Manager (PBM) has updated its formulary and PDL files, at least weekly. At HHSC’s direction, the MCO or PBM must be able perform off-cycle formulary and PDL file updates. Such updates must be completed within one (1) Business Day. The MCO must ensure that prescribers have the ability to utilize real time e-prescribing, which at a minimum will allow for: eligibility confirmation, PDL benefit confirmation, identification of “alternative” (i.e., preferred) drugs that can be used in place of non-preferred drugs, medication history, and prescription routing. The MCO must allow pharmacies to fill prescriptions for covered drugs ordered by any licensed provider regardless of Network participation...
Pharmacy Services. PHARMACY agrees to render Covered Prescription Services to Members in accordance with the terms and conditions of this Agreement. PHARMACY shall provide Prescription Services to Members for Covered Products in as reasonably timely a manner as provided to other patrons and shall not discriminate against an eligible Member.
