Pharmacy. 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. Drugs with manual prior authorization criteria are developed and maintained by the Division and can be found on the Division’s website. When changes occur to these criteria, the Division will notify the Contractor. Updated criteria must be implemented upon receipt. Drugs with electronic prior authorization criteria (Smart PA) are addressed in Section 0.X.Xxxx Exchange Requirements, of this Contract. The Contractor may approve non-preferred drugs when one of the following Prior Authorization criteria is satisfied: a. Member experiences an adverse event(s) or reaction(s) to preferred medications; or b. Contraindications to preferred medications (i.e. drug interaction, existing medical condition preventing the use of preferred medications). c. 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 allows pharmacy providers thirty (30) calendar days to submit a request for reconsideration after receipt of a Prior Authorization denial. The Contractor and its Subcontractor or delegated vendors shall adhere to this time frame.
Appears in 6 contracts
Samples: Contract Between the State of Mississippi Division of Medicaid and a Coordinated Care Organization (Cco), Contract Between the State of Mississippi Division of Medicaid and a Coordinated Care Organization (Cco), Contract Between the State of Mississippi Division of Medicaid and a Coordinated Care Organization (Cco)
