Common use of Preferred Drug List Requirements Clause in Contracts

Preferred Drug List Requirements. The Contractor shall maintain a preferred drug list (PDL). In accordance with IC 12-15- 35-46, State approval of the PDL shall be required prior to Contractor implementation. The Contractor shall submit the proposed PDL to FSSA at least thirty-five (35) calendar days before the intended PDL implementation date. The FSSA shall submit the PDL to the DUR Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL. The DUR Board will provide a recommendation regarding approval of the PDL in accordance with the terms of IC 00-00-00-00. FSSA will approve, disapprove or modify the formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL. In accordance with IC 00- 00-00-00, prior to removing one (1) or more drugs from the PDL or placing new restrictions on one (1) or more drugs, the Contractor shall submit the proposed change to FSSA which shall forward the proposal to the DUR Board. Such changes shall be submitted at least thirty-five (35) calendar days in advance of the proposed change. The Contractor shall also meet with FSSA staff and/or the DUR Board, as directed by FSSA, to answer questions about the clinical rationale for the proposed change. The Contractor is not required to seek approval from the State in order to add a drug to the PDL; however, the Contractor shall notify FSSA of any addition to the PDL within thirty (30) days after making the addition. The Contractor shall maintain an Over-the-Counter (OTC) Drug Formulary which contains, at a minimum, the same items included in the Hoosier Healthwise fee-for- service OTC Formulary and as updated by the DUR Board. Any additions to the Contractor OTC Drug Formulary are required to only be from participating rebating labelers. The PDL shall be made readily available to providers in the Contractor’s network and to members. The PDL shall be updated to reflect all changes in the status of a drug or addition of new drugs. The Contractor shall also support e-Prescribing technologies to communicate the PDL to prescribers through electronic medical records (EMRs) and e- Prescribing applications. Refer to 3.8.5 for additional requirements on e-Prescribing. Notwithstanding the foregoing, the Contractor may opt to utilize the State’s PDL and to contract with the State’s PBM contractor for pharmacy claims processing. If the Contractor takes this approach, a Contractor Pharmacy and Therapeutics Committee shall not be required and the Contractor shall be permitted to utilize the work of the Therapeutics Committee and DUR Board in maintaining the State’s PDL. Also, prescriptions obtained by a Hoosier Care Connect member that are not otherwise exempt on the basis outlined in Section 12.2, are subject to the copayment amounts set forth in the same Section. Copayments assessed to the Hoosier Care Connect member at the point of sale may not exceed the total cost of the drug.

Preferred Drug List Requirements. The Contractor shall maintain a preferred drug list (PDL). In accordance with IC 12-15- 35-46, State approval of the PDL shall be required prior to Contractor implementation. The Contractor shall submit the proposed PDL to FSSA at least thirty-five (35) calendar days before the intended PDL implementation date. The FSSA shall submit the PDL to the DUR Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL. The DUR Board will provide a recommendation regarding approval of the PDL in accordance with the terms of IC 00-00-00-00. FSSA will approve, disapprove or modify the formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. Per CFR 438.10(i)(1)-(2), the Contractor shall make available in electronic or paper form, the covered drug list(s) of medications including the reference brand and generic names of each drug as well as what tier each drug is on. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL. In accordance with IC 00- 00-00-00, prior to removing one (1) or more drugs from the PDL or placing new restrictions on one (1) or more drugs, the Contractor shall submit the proposed change to FSSA which shall forward the proposal to the DUR Board. Such changes shall be submitted at least thirty-five (35) calendar days in advance of the proposed change. The Contractor shall also meet with FSSA staff and/or the DUR Board, as directed by FSSA, to answer questions about the clinical rationale for the proposed change. The Contractor is not required to seek approval from the State in order to add a drug to the PDL; however, the Contractor shall notify FSSA of any addition to the PDL within thirty (30) days after making the addition. The In accordance with CMS-2390-F, the Contractor shall maintain an Over-the-Counter (OTC) Drug Formulary which containsdemonstrate prescription drug coverage consistent with the amount, at a minimumduration, and scope of the same items included in the Hoosier Healthwise fee-for- for-service OTC Formulary and as updated by the DUR Board. Any additions to the Contractor OTC Drug Formulary are required to only be from participating rebating labelers. The PDL shall be made readily available to providers in the Contractor’s network and to members. The PDL shall be updated to reflect all changes in the status of a drug or addition of new drugsprogram. The Contractor shall also support e-Prescribing technologies to communicate the PDL to prescribers through electronic medical records (EMRs) and e- Prescribing applications. Refer to 3.8.5 for additional requirements on e-Prescribing. Notwithstanding the foregoing, the Contractor may opt to utilize the State’s PDL and to contract engage with the State’s PBM contractor State to develop universal medically necessary prior authorization criteria for pharmacy claims processingIHCP. If the Contractor takes this approach, a Contractor Pharmacy and Therapeutics Committee shall not be required and the The Contractor shall be permitted to utilize implement the work of the Therapeutics Committee universal IHCP criteria into their program and DUR Board in maintaining the State’s PDL. Also, prescriptions obtained by a Hoosier Care Connect member that are not otherwise exempt on the basis outlined in Section 12.2, are subject to the copayment amounts set forth in the same Section. Copayments assessed to the Hoosier Care Connect member at the point of sale may not exceed the total cost of the drugutilize more restrictive criteria.

Preferred Drug List Requirements. The Contractor shall maintain a preferred drug list (PDL). In accordance with IC 12-15- 35-46, State approval of the PDL shall be required prior to Contractor implementation. The Contractor shall submit the proposed PDL to FSSA at least thirty-five (35) calendar days before the intended PDL implementation date. The FSSA shall submit the PDL to the DUR Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL. The DUR Board will provide a recommendation regarding approval of the PDL in accordance with the terms of IC 00-00-00-00. FSSA will approve, disapprove or modify the formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty six ty (60) days after receiving notice of the decision. Per CFR 438.10(i)(1)-(2), the Contractor shall make available in electronic or paper form, the covered drug list(s) of medications including the reference brand and generic names of each drug as well as what tier each drug is on. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL. In accordance with IC 00- 00-00-00, prior to removing one (1) or more drugs from the PDL or placing new restrictions on one (1) or more drugs, the Contractor shall submit the proposed change to FSSA which shall forward the proposal to the DUR Board. Such changes shall be submitted at least thirty-five (35) calendar days in advance of the proposed change. The Contractor shall also meet with FSSA staff and/or the DUR Board, as directed by FSSA, to answer questions about the clinical rationale for the proposed change. The Contractor is not required to seek approval from the State in order to add a drug to the PDL; however, the Contractor shall notify FSSA of any addition to the PDL within thirty (30) days after making the addition. The In accordance with CMS-2390-F, the Contractor shall maintain an Over-the-Counter (OTC) Drug Formulary which containsdemonstrate prescription drug coverage consistent with the amount, at a minimumduration, and scope of the same items included in the Hoosier Healthwise fee-for- for-service OTC Formulary and as updated by the DUR Board. Any additions to the Contractor OTC Drug Formulary are required to only be from participating rebating labelers. The PDL shall be made readily available to providers in the Contractor’s network and to members. The PDL shall be updated to reflect all changes in the status of a drug or addition of new drugsprogram. The Contractor shall also support e-Prescribing technologies to communicate the PDL to prescribers through electronic medical records (EMRs) and e- Prescribing applications. Refer to 3.8.5 for additional requirements on e-Prescribing. Notwithstanding the foregoing, the Contractor may opt to utilize the State’s PDL and to contract engage with the State’s PBM contractor State to develop universal medically necessary prior authorization criteria for pharmacy claims processingIHCP. If the Contractor takes this approach, a Contractor Pharmacy and Therapeutics Committee shall not be required and the The Contractor shall be permitted to utilize implement the work of the Therapeutics Committee universal IHCP criteria into their program and DUR Board in maintaining the State’s PDL. Also, prescriptions obtained by a Hoosier Care Connect member that are not otherwise exempt on the basis outlined in Section 12.2, are subject to the copayment amounts set forth in the same Section. Copayments assessed to the Hoosier Care Connect member at the point of sale may not exceed the total cost of the drugutilize more restrictive criteria.

Preferred Drug List Requirements. The Contractor shall maintain a preferred drug list (PDL). In accordance with IC 12-15- 35-46, State approval of the PDL shall be required prior to Contractor implementation. The Contractor shall submit the proposed PDL to FSSA OMPP at least thirty-five thirty -five (35) calendar days before the intended PDL implementation date. The FSSA OMPP shall submit the PDL to the DUR Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL. The DUR Board will provide EXHIBIT 1 SCOPE OF WORK – HEALTHY INDIANA PLAN a recommendation regarding approval of the PDL in accordance with the terms of IC 00-00- 00-00-00. FSSA OMPP will approve, disapprove disapprove, or modify the formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. Per CFR 438.10(i)(1)-(2), the Contractor shall make available in electronic or paper form, the covered drug list(s) of medications including the reference brand and generic names of each drug as well as what tier each drug is on. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL. In accordance with IC 00- 00-00-00, prior to removing one (1) or more drugs from the PDL or placing new restrictions on one (1) or more drugs, the Contractor shall submit the proposed change to FSSA OMPP which shall forward the proposal to the DUR Board. Such changes shall be submitted at least thirty-five (35) calendar days in advance of the proposed change. The Contractor shall also meet with FSSA OMPP staff and/or the DUR Board, as directed by FSSA, to answer questions about the clinical rationale for the proposed change. The Contractor is not required to seek approval from the State in order to add a drug to the PDL; however, the Contractor shall notify FSSA OMPP of any addition to the PDL within thirty (30) days after making the addition. In accordance with CMS-2390-F and 42 CFR 438.210, the Contractor shall demonstrate prescription drug coverage consistent with the amount, duration, and scope of the fee-for- service program. The Contractor shall engage with the State to develop medically necessary prior authorization criteria for IHCP. The Contractor shall implement the universal IHCP criteria into their program and may not utilize more restrictive criteria, including, but not limited to quantitative and non-quantitative treatment limits. The Contractor shall maintain an Over-the-Counter (OTC) Drug Formulary and Pharmacy Supplements Formulary which contains, at a minimum, the same items included in the Hoosier Healthwise fee-for- service FFS OTC Drug Formulary and Pharmacy Supplements Formulary and as updated by the DUR Board. Any additions to the Contractor OTC Drug Formulary are required to only be from participating rebating labelers. The PDL shall be made readily available to providers in the Contractor’s network and to membersmembers by linking to the Pharmacy Services page on xxxxx://xxx.xx.xxx/medicaid/. The PDL shall be formatted in a similar manner to the FFS PDL, listing both preferred and nonpreferred drugs, as well as applicable edits. The PDL shall be updated and posted on or before the intended PDL implementation date to reflect all changes in the status of a drug or addition of new drugs. The Contractor shall also support e-Prescribing technologies to communicate the PDL to prescribers through electronic medical records (EMRs) and e- e-Prescribing applications. Refer to 3.8.5 Section 3.4.5 for additional requirements on e-Prescribing. Notwithstanding the foregoing, the Contractor may opt to utilize the State’s PDL and to contract with the State’s PBM contractor for pharmacy claims processing. If the Contractor takes this approach, a Contractor Pharmacy and Therapeutics Committee shall not be required and the Contractor shall be permitted to utilize the work of the Therapeutics Committee and DUR Board in maintaining the State’s PDL. Also, prescriptions obtained by a Hoosier Care Connect HIP member that are not otherwise exempt on the basis outlined in Section 12.213.0, are subject to the copayment amounts set forth in the same Section. Copayments assessed to the Hoosier Care Connect HIP member at the point of sale may not exceed the total cost of the drug. EXHIBIT 1 SCOPE OF WORK – HEALTHY INDIANA PLAN While the underlying drug formulary for the HIP Plus and the HIP Basic plans will be identical, additional pharmacy services will differ between the plans in order to align the benefits with the overall program goals aimed at encouraging member participation in HIP Plus.

Preferred Drug List Requirements. The Contractor shall maintain a preferred drug list (PDL). In accordance with IC 12-15- 35-46, State approval of the PDL shall be required prior to Contractor implementation. The Contractor shall submit the proposed PDL to FSSA OMPP at least thirty-five (35) calendar days before the intended PDL implementation date. The FSSA OMPP shall submit the PDL to the DUR Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL. The DUR Board will provide a recommendation regarding approval of the PDL in accordance with the terms of IC 00-00- 00-00-00. FSSA OMPP will approve, disapprove disapprove, or modify the formulary based on the DUR EXHIBIT 1 SCOPE OF WORK – HEALTHY INDIANA PLAN Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. Per CFR 438.10(i)(1)-(2), the Contractor shall make available in electronic or paper form, the covered drug list(s) of medications including the reference brand and generic names of each drug as well as what tier each drug is on. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL. In accordance with IC 00- 00-00-00, prior to removing one (1) or more drugs from the PDL or placing new restrictions on one (1) or more drugs, the Contractor shall submit the proposed change to FSSA OMPP which shall forward the proposal to the DUR Board. Such changes shall be submitted at least thirty-five (35) calendar days in advance of the proposed change. The Contractor shall also meet with FSSA OMPP staff and/or the DUR Board, as directed by FSSA, to answer questions about the clinical rationale for the proposed change. The Contractor is not required to seek approval from the State in order to add a drug to the PDL; however, the Contractor shall notify FSSA OMPP of any addition to the PDL within thirty (30) days after making the addition. In accordance with CMS-2390-F and 42 CFR 438.210, the Contractor shall demonstrate prescription drug coverage consistent with the amount, duration, and scope of the fee-for- service program. The Contractor shall engage with the State to develop medically necessary prior authorization criteria for IHCP. The Contractor shall implement the universal IHCP criteria into their program and may not utilize more restrictive criteria, including, but not limited to quantitative and non-quantitative treatment limits. The Contractor shall maintain an Over-the-Counter (OTC) Drug Formulary and Pharmacy Supplements Formulary which contains, at a minimum, the same items included in the Hoosier Healthwise fee-for- service FFS OTC Drug Formulary and Pharmacy Supplements Formulary and as updated by the DUR Board. Any additions to the Contractor OTC Drug Formulary are required to only be from participating rebating labelers. The PDL shall be made readily available to providers in the Contractor’s network and to membersmembers by linking to the Pharmacy Services page on xxxxx://xxx.xx.xxx/medicaid/. The PDL shall be formatted in a similar manner to the FFS PDL, listing both preferred and nonpreferred drugs, as well as applicable edits. The PDL shall be updated and posted on or before the intended PDL implementation date to reflect all changes in the status of a drug or addition of new drugs. The Contractor shall also support e-Prescribing technologies to communicate the PDL to prescribers through electronic medical records (EMRs) and e- e-Prescribing applications. Refer to 3.8.5 Section 3.4.5 for additional requirements on e-Prescribing. Notwithstanding the foregoing, the Contractor may opt to utilize the State’s PDL and to contract with the State’s PBM contractor for pharmacy claims processing. If the Contractor takes this approach, a Contractor Pharmacy and Therapeutics Committee shall not be required and the Contractor shall be permitted to utilize the work of the Therapeutics Committee and DUR Board in maintaining the State’s PDL. Also, prescriptions obtained by a Hoosier Care Connect HIP member that are not otherwise exempt on the basis outlined in Section 12.213.0, are subject to the copayment amounts set forth in the same Section. Copayments assessed to the Hoosier Care Connect HIP member at the point of sale may not exceed the total cost of the drug. While the underlying drug formulary for the HIP Plus and the HIP Basic plans will be EXHIBIT 1 SCOPE OF WORK – HEALTHY INDIANA PLAN identical, additional pharmacy services will differ between the plans in order to align the benefits with the overall program goals aimed at encouraging member participation in HIP Plus.

Preferred Drug List Requirements. The Contractor shall maintain a preferred drug list (PDL). In accordance with IC 12-15- 35-46, State approval of the PDL shall be required prior to Contractor implementation. The Contractor shall submit the proposed PDL to FSSA OMPP at least thirty-five thirty -five (35) calendar days before the intended PDL implementation date. The FSSA OMPP shall submit the PDL to the DUR Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL. The DUR Board will provide a recommendation regarding approval of the PDL in accordance with the terms of IC 00-00- 00-00-00. FSSA OMPP will approve, disapprove disapprove, or modify the formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. Per CFR 438.10(i)(1)-(2), the Contractor shall make available in electronic or paper form, the covered drug list(s) of medications including the reference brand and generic names of each drug as well as what tier each drug is on. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL. In accordance with IC 00- 00-00-00, prior to removing one (1) or more drugs from the PDL or placing new restrictions on one (1) or more drugs, the Contractor shall submit the proposed change to FSSA OMPP which shall forward the proposal to the DUR Board. Such changes shall be submitted at least thirty-five (35) calendar days in advance of the proposed change. The Contractor shall also meet with FSSA OMPP staff and/or the DUR Board, as directed by FSSA, to answer questions about the clinical rationale for the proposed change. The Contractor is not required to seek approval from the State in order to add a drug to the PDL; however, the Contractor shall notify FSSA OMPP of any addition to the PDL within thirty (30) days after making the addition. The In accordance with CMS-2390-F and 42 CFR 438.210, the Contractor shall maintain an Over-the-Counter (OTC) Drug Formulary which containsdemonstrate prescription drug coverage consistent with the amount, at a minimumduration, and scope of the same items included in the Hoosier Healthwise fee-for- service OTC Formulary and as updated by the DUR Board. Any additions to the Contractor OTC Drug Formulary are required to only be from participating rebating labelers. The PDL shall be made readily available to providers in the Contractor’s network and to members. The PDL shall be updated to reflect all changes in the status of a drug or addition of new drugsprogram. The Contractor shall also support e-Prescribing technologies to communicate the PDL to prescribers through electronic medical records (EMRs) and e- Prescribing applications. Refer to 3.8.5 for additional requirements on e-Prescribing. Notwithstanding the foregoing, the Contractor may opt to utilize the State’s PDL and to contract engage with the State’s PBM contractor State to develop medically necessary prior authorization criteria for pharmacy claims processingIHCP. If the Contractor takes this approach, a Contractor Pharmacy and Therapeutics Committee shall not be required and the The Contractor shall be permitted to utilize implement the work of the Therapeutics Committee universal IHCP criteria into their program and DUR Board in maintaining the State’s PDL. Also, prescriptions obtained by a Hoosier Care Connect member that are not otherwise exempt on the basis outlined in Section 12.2, are subject to the copayment amounts set forth in the same Section. Copayments assessed to the Hoosier Care Connect member at the point of sale may not exceed the total cost of the drug.utilize more restrictive criteria, including, but not limited to quantitative and non-quantitative treatment limits. EXHIBIT 1

Preferred Drug List Requirements. The Contractor shall maintain a preferred drug list (PDL). In accordance with IC 1200- 00-15- 3500-4600, State approval of the PDL shall be required prior to Contractor implementation. The Contractor shall submit the proposed PDL to FSSA OMPP at least thirty-five (35) calendar days before the intended PDL implementation date. The FSSA OMPP shall submit the PDL to the DUR Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL. The DUR Board will provide a recommendation regarding approval of the PDL in accordance with the terms of IC 00-00-00-00. FSSA OMPP will approve, disapprove disapprove, or modify the formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. Per CFR 438.10(i)(1)-(2), the Contractor shall make available in electronic or paper form, the covered drug list(s) of medications including the reference brand and generic names of each drug as well as what tier each drug is on. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL. In accordance with IC 00- 00-00-00-00, prior to removing one (1) or more drugs from the PDL or placing new restrictions on one (1) or more drugs, the Contractor shall submit the proposed change to FSSA OMPP which shall forward the proposal to the DUR Board. Such changes shall be submitted at least thirty-five (35) calendar days in advance of the proposed change. The Contractor shall also meet with FSSA OMPP staff and/or the DUR Board, as directed by FSSA, to answer questions about the clinical rationale for the proposed change. The Contractor is not required to seek approval from the State in order to add a drug to the PDL; however, the Contractor shall notify FSSA OMPP of any addition to the PDL within thirty (30) days after making the addition. EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE In accordance with CMS-2390-F and 42 CFR 438.210, the Contractor shall demonstrate prescription drug coverage consistent with the amount, duration, and scope of the fee-for-service program. The Contractor shall engage with the State to develop medically necessary prior authorization criteria for IHCP. The Contractor shall implement the universal IHCP criteria into their program and may not utilize more restrictive criteria, including, but not limited to quantitative and non-quantitative treatment limits. The Contractor shall maintain an Over-the-Counter (OTC) Drug Formulary and Pharmacy Supplements Formulary which contains, at a minimum, the same items included in the Hoosier Healthwise fee-for- service FFS OTC Drug Formulary and Pharmacy Supplements Formulary and as updated by the DUR Board. Any additions to the Contractor OTC Drug Formulary are required to only be from participating rebating labelers. The PDL shall be made readily available to providers in the Contractor’s network and to membersmembers by linking to the Pharmacy Services page on xxxxx://xxx.xx.xxx/medicaid/. The PDL shall be formatted in a similar manner to the FFS PDL, listing both preferred and nonpreferred drugs, as well as applicable edits. The PDL shall be updated and posted on or before the intended PDL implementation date to reflect all changes in the status of a drug or addition of new drugs. The Contractor shall also support e-Prescribing technologies to communicate the PDL to prescribers through electronic medical records (EMRs) and e- e-Prescribing applications. Refer to 3.8.5 Section 3.4.5 for additional requirements on e-Prescribing. Notwithstanding the foregoing, the Contractor may opt to utilize the State’s PDL and to contract with the State’s PBM contractor for pharmacy claims processing. If the Contractor takes this approach, a Contractor Pharmacy and Therapeutics Committee shall not be required and the Contractor shall be permitted to utilize the work of the Therapeutics Committee and DUR Board in maintaining the State’s PDL. Also, prescriptions obtained by a Hoosier Care Connect Healthwise member that are not otherwise exempt on the basis outlined in Section 12.23.4.11, are subject to the copayment amounts set forth in the same Section. Copayments assessed to the Hoosier Care Connect Healthwise member at the point of sale may not exceed the total cost of the drug.