Common use of Pharmacy Services Clause in Contracts

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. The MCO will encourage Network pharmacies to also become Medicaid-enrolled durable medical equipment (DME) providers. The MCO must educate Network Providers about how to access the Medicaid and CHIP formularies and the Medicaid PDL on HHSC’s website, and how to use HHSC’s free subscription service for accessing such information through the internet or hand-held devices. The MCO is responsible for negotiating reasonable pharmacy provider reimbursement rates, including individual MCO maximum allowable cost (MAC) rates. The MCO must ensure that, as an aggregate, rates comply with 42 C.F.R. Part 50, Subpart E, regarding upper payment limits. The MCO must comply with the requirements of Sections 8.2.1 (Medicaid) and 8.4.3 (CHIP) regarding payment of out-of-network pharmacy claims.

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. If the PDL is developed by the MCO, it must review the PDL at least annually and new drugs as they are introduced to the market. 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. The MCO will encourage Network pharmacies to also become Medicaid-enrolled durable medical equipment (DME) providers. The MCO must educate Network Providers about how to access the Medicaid and CHIP formularies and the Medicaid PDL on HHSC’s website, and how to use HHSC’s free subscription service for accessing such information through the internet or hand-held devices. The MCO is responsible for negotiating reasonable pharmacy provider reimbursement rates, including individual MCO maximum allowable cost (MAC) rates. The MCO must ensure that, as an aggregate, rates comply with 42 C.F.R. Part 50, Subpart E, regarding upper payment limits. The MCO must comply with the requirements of Sections 8.2.1 (Medicaid) and 8.4.3 (CHIP) regarding payment of out-of-network pharmacy claims.

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. The MCO will encourage Network pharmacies to also become Medicaid-enrolled durable medical equipment (DME) providers. The MCO must educate Network Providers about how to access the Medicaid and CHIP formularies and the Medicaid PDL on HHSC’s website, and how to use HHSC’s free subscription service for accessing such information through the internet or hand-held devices. The MCO is responsible for negotiating reasonable pharmacy provider reimbursement rates, including individual MCO maximum allowable cost (MAC) rates. The MCO must ensure that, as an aggregate, rates comply with 42 C.F.R. Part 50, Subpart E, regarding upper payment limits. The MCO must comply with the requirements of Sections 8.2.1 (Medicaid) and 8.4.3 (CHIP) regarding payment of out-of-network pharmacy claims.