Prescribed Drug Services. a. The Health Plan shall provide those products and services associated with the dispensing of medicinal drugs pursuant to a valid prescription, as defined in Chapter 465, F.S. Prescribed Drug Services generally include all prescription drugs listed in the Agency’s Prescribed Drug List (“PDL”). See Section 409.91195, F.S. The PDL shall include at least two (2) products, when available, in each therapeutic class. Antiretroviral agents are not subject to the PDL. Pursuant to Section 409.912(39), F.S., policy requirements include, but are not limited to, the following: (1) The Health Plan shall make available those drugs and dosage forms listed in the PDL. (2) The Health Plan shall not arbitrarily deny or reduce the amount, duration or scope of prescriptions solely based on the Enrollee’s diagnosis, type of illness or condition. The Health Plan may place appropriate limits on prescriptions based on criteria such as Medical Necessity, or for the purpose of utilization control, provided the Health Plan reasonably expects said limits to achieve the purpose of the Prescribed Drug Services set forth in the Medicaid State Plan. (3) The Health Plan shall make available those drugs not on the PDL, when requested and approved, if the drugs on the PDL have been used in a step therapy sequence or when other documentation is provided. (4) The Health Plan shall submit an updated PDL to the Agency annually, by October 1 of each Contract Year, and provide thirty (30) days written notice of any changes to the Bureau of Managed Health Care and Pharmacy Services. b. The Health Plan shall provide to Enrollees, who desire to quit smoking, one (1) course of nicotine replacement therapy, of twelve (12) weeks duration, or the manufacturer’s recommended duration, per year. The Health Plan may use either nicotine transdermal patches or nicotine gum. c. If the Health Plan has authorization requirements for prescribed drug services, the Health Plan shall comply with all aspects of the Settlement Agreement to Xxxxxxxxx, et. al.
Appears in 2 contracts
Samples: Health Care Services Agreement, Health Care Services Contract (Amerigroup Corp)
Prescribed Drug Services. a. The Health Plan shall provide those products and services associated with the dispensing of medicinal drugs pursuant to a valid prescription, as defined in Chapter 465, F.S. Prescribed Drug Services generally include all prescription drugs listed in the Agency’s Prescribed Drug List (“PDL”). See Section 409.91195, F.S. The PDL shall include at least two (2) products, when available, in each therapeutic class. Antiretroviral agents are not subject to the PDL. Pursuant to Section 409.912(39), F.S., policy requirements include, but are not limited to, the following:
(1) The Health Plan shall make available those drugs and dosage forms listed in the PDL.
(2) The Health Plan shall not arbitrarily deny or reduce the amount, duration or scope of prescriptions solely based on the Enrollee’s diagnosis, type of illness or condition. The Health Plan may place appropriate limits on prescriptions based on criteria such as Medical Necessity, or for the purpose of utilization control, provided the Health Plan reasonably expects said limits to achieve the purpose of the Prescribed Drug Services set forth in the Medicaid State Plan.
(3) The Health Plan shall make available those drugs not on the PDL, when requested and approved, if the drugs on the PDL have been used in a step therapy sequence or when other documentation is provided.
(4) The Health Plan shall submit an updated PDL to the Agency annually, by October 1 of each Contract Year, and provide thirty (30) days written notice of any changes to the Bureau of Managed Health Care and Pharmacy Services.
b. The Health Plan shall provide to Enrollees, who desire to quit smoking, one (1) course of nicotine replacement therapy, of twelve (12) weeks duration, or the manufacturer’s recommended duration, per year. The Health Plan may use either nicotine transdermal patches or nicotine gum.
c. If the Health Plan has authorization requirements for prescribed drug services, the Health Plan shall comply with all aspects of the Settlement Agreement to Xxxxxxxxx, et. al. x. Xxxxxx (case number 02-20964 Civ-Gold/Xxxxxxxx) (HSA). An HSA situation arises when an Enrollee attempts to fill a prescription at a participating pharmacy location and is unable to receive his/her prescription as a result of:
(1) An unreasonable delay in filling the prescription;
(2) A denial of the prescription;
(3) The reduction of a prescribed good or service; and/or
(4) The termination of a prescription.
d. The Health Plan shall ensure that its Enrollees are receiving the functional equivalent of those goods and services received by non-Medicaid Reform fee-for-service Medicaid Recipients in accordance with the HSA.
(1) The Health Plan shall maintain a log of all correspondences and communications from Enrollees relating to the HSA Ombudsman process. The “Ombudsman Log” shall contain, at a minimum, the Enrollee’s name, address and telephone number and any other contact information, the reason for the participating pharmacy location’s denial (an unreasonable delay in filling a prescription, a denial of a prescription and/or the termination of a prescription), the pharmacy’s name (and store number, if applicable), the date of the call, a detailed explanation of the final resolution, and the name of prescribed good or service.
Appears in 2 contracts
Samples: Health Care Services Contract (Wellcare Health Plans, Inc.), Health Care Services Contract (Wellcare Health Plans, Inc.)
Prescribed Drug Services. a. The Health Plan shall provide those products and services associated with the dispensing of medicinal drugs pursuant to a valid prescription, as defined in Chapter 465, F.S. Prescribed Drug Services drug services generally include all prescription drugs listed in the Agency’s Prescribed Preferred Drug List (“PDL”). See Section s. 409.91195, F.S. The Health Plan’s PDL shall include at least two (2) products, when available, in each therapeutic class. Antiretroviral agents are not subject to the PDL. Pursuant to Section s. 409.912(39), F.S., policy requirements include, but are not limited to, the following:
(1) The Health Plan shall make available those drugs and dosage forms listed in the its PDL.
(2) The Health Plan shall not arbitrarily deny or reduce the amount, duration or scope of prescriptions solely based on the Enrolleeenrollee’s diagnosis, type of illness or condition. The Health Plan may place appropriate limits on prescriptions based on criteria such as Medical Necessitymedical necessity, or for the purpose of utilization control, provided the Health Plan reasonably expects said limits to achieve the purpose of the Prescribed Drug Services prescribed drug services set forth in the Medicaid State Plan.
(3) The Health Plan shall make available those drugs not on the its PDL, when requested and approved, if the drugs on the PDL have been used in a step therapy sequence or when other medical documentation is provided.
(4) The Health Plan shall submit an updated a PDL that has been revised and approved by the Health Plan’s Pharmacy and Therapeutics (P&T) Committee to BMHC and the Agency annually, Bureau of Pharmacy Services by October 1 of each Contract Yearyear, and provide thirty forty-five (3045) days calendar days’ written notice of any changes to both bureaus. The attestation for this submission must include the Bureau dates for the P&T committee meeting(s) in which the PDL changes were discussed.
(a) The Health Plan shall keep on file, for Agency review, copies of Managed minutes and decision points from the P&T Committee meetings that support the choice of medications on the PDL. The Health Care Plan’s PDL shall be a listing of medications that the physician and Pharmacy pharmacist members of the Health Plan’s P&T Committee deem clinically appropriate and cost effective for the population enrolled in the Health Plan.
(b) See Section IV, Enrollee services, Item A., Enrollee Services, sub-item 13,. of this Attachment for enrollee notice requirements.
(c) The Health Plan shall notify providers who may prescribe or are currently prescribing a drug that the Health Plan is deleting from its PDL at least thirty (30) calendar days prior to the effective date of the change.
(d) If the Health Plan adopts the Medicaid PDL, the Health Plan shall be exempt from such reporting. Information on the Health Plan’s use of the PDL is in Attachment I and Attachment II, Exhibit 5, Covered Services.
(5) Antiretroviral agents are not subject to the PDL. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract
b. The Health Plan shall provide may delegate any or all functions to Enrollees, who desire to quit smoking, one (1) course of or more pharmacy benefits administrators (PBA). Before entering into a subcontract, the Health Plan shall work with the Agency’s fiscal agent.
c. The Health Plan shall continue the medication prescribed to the enrollee in a state mental health treatment facility for at least ninety (90) days after the facility discharges the enrollee, unless the Health Plan's prescribing psychiatrist, in consultation and agreement with the facility's prescribing physician, determines that the medications:
(1) Are not medically necessary; or
(2) Are potentially harmful to the enrollee.
d. The Health Plan shall provide nicotine replacement therapytherapy to enrollees who want to quit smoking as follows: The Health Plan shall use transdermal nicotine patches, of twelve gum or lozenges containing nicotine, and/or bupropion tablets (12generic for Zyban® when used in a smoking cessation program for no more than twenty-four (24) weeks durationper three-hundred sixty-five (365) days, or the manufacturer’s recommended durationrecommendation, per year. The Health Plan may use either nicotine transdermal patches or nicotine gumwhichever is less.
c. e. If the Health Plan has authorization requirements for prescribed drug services, the Health Plan shall comply with all aspects of the Settlement Agreement to XxxxxxxxxHxxxxxxxx, etet ax x. Xxxxxx (case number 02-20964 Civ-Gold/Sxxxxxxx) (HSA). alAn HSA situation arises when an enrollee attempts to fill a prescription at a participating pharmacy location and is unable to receive the prescription as a result of:
(1) An unreasonable delay in filling the prescription;
(2) A denial of the prescription;
(3) The reduction of a prescribed good or service; and/or
(4) The termination of a prescription.
f. The Health Plan shall ensure that its enrollees are receiving the functional equivalent of those goods and services received by fee-for-service Medicaid recipients in accordance with the HSA.
(1) The Health Plan shall maintain a log of all correspondence and communications from enrollees relating to the HSA ombudsman process. The ombudsman log shall contain, at a minimum, the enrollee’s name, address and telephone number and any other contact information, the reason for the participating pharmacy location’s denial (an unreasonable delay in filling a prescription, a denial of a prescription and/or the termination of a prescription), the pharmacy’s name (and store number, if applicable), the date of the call, a detailed explanation of the final resolution, and the name of the prescribed good or service. The ombudsman log report shall be submitted quarterly to BMHC, as required in Attachment II, Section XII, Reporting Requirements. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract
(2) The Health Plan’s enrollees are third party beneficiaries for this section of the Contract.
(3) The Health Plan shall conduct annual HSA surveys of no less than five percent (5%) of all participating pharmacy locations to ensure compliance with the HSA.
(a) The Health Plan may survey less than five percent (5%), with written approval from the Agency, if the Health Plan can show that the number of participating pharmacies it surveys is a statistically significant sample that adequately represents the pharmacies that have contracted with the Health Plan to provide pharmacy services.
(b) The Health Plan shall not include in the HSA survey any participating pharmacy location that the Health Plan found to be in complete compliance with the HSA requirements within the past twelve (12) months.
(c) The Health Plan shall require all participating pharmacy locations that fail any aspect of the HSA survey to undergo mandatory training within six (6) months and then be re-evaluated within one (1) month of the training to ensure that the pharmacy location is in compliance with the HSA.
(d) The Health Plan shall ensure that it complies with all aspects and surveying requirements set forth in Policy Transmittal 06-01, Hxxxxxxxx Settlement Requirements, an electronic copy of which can be found at:
(e) The Health Plan shall submit a report annually, by August 1 of each Contract year to BMHC, providing survey results following requirements in Attachment II, Section XII, Reporting Requirements.
(4) The Health Plan shall offer training to all new and existing participating pharmacy locations about the HSA requirements.
(5) The Health Plan shall ensure its PBA provides the following electronic message alerting the pharmacist to provide Medicaid recipients with the Hxxxxxxxx notice/pamphlet when coverage is rejected due to the drug not being on the Health Plan’s PDL:
g. The Health Plan shall cover the cost of a brand-name drug if the prescriber:
(1) Writes in his/her own handwriting on the valid prescription that the “Brand Name is Medically Necessary” (pursuant to s. 465.025, F.S.); and
(2) Submits a completed “Multisource Drug and Miscellaneous Prior Authorization” form to the Health Plan indicating that the enrollee has had an adverse reaction WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract to a generic drug or has had, in the prescriber’s medical opinion, better results when taking the brand-name drug.
h. Hemophilia factor-related drugs identified by the Agency for distribution through the Comprehensive Hemophilia Disease Management Program are reimbursed on a fee-for-service basis. During operation of the Comprehensive Hemophilia Disease Management Program, the Health Plan shall coordinate the care of its enrollees with Agency-approved organizations and shall not be responsible for the distribution of hemophilia-related drugs.
i. Capitated Health Plans shall submit behavioral health pharmacy encounter data to the BMHC secure file transfer protocol site in a format supplied by the Agency on an ongoing quarterly schedule, as specified in Attachment II, Section XII, Reporting Requirements and the Health Plan Report Guide.
j. Capitated Health Plans covering Reform populations shall submit a complete pharmacy drug list to the Agency‘s Reform choice counseling vendor annually by December 1, using the format provided in the Health Plan Report Guide referenced in Attachment II, Section XII, Reporting Requirements.
k. Capitated Health Plans may have a pharmacy lock-in program that conforms to the requirements in the Medicaid Prescribed Drug Services Coverage, Limitations and Reimbursement Handbook, provided it is submitted in writing to BMHC and approved by the Agency in advance of implementation.
l. If there is a dispute between the Agency and the drug manufacturer regarding federal drug rebates, the Health Plan shall assist the Agency in dispute resolution by providing information regarding claims and provider details. Failure to collect drug rebates due to the Health Plan’s failure to assist the Agency will result in the Agency’s recouping from the Health Plan any determined uncollected rebates.
m. The Health Plan shall require that prescriptions for psychotropic medication prescribed for an enrollee under the age of thirteen (13) be accompanied by the express written and informed consent of the enrollee’s parent or legal guardian. Psychotropic (psychotherapeutic) medications include antipsychotics, antidepressants, antianxiety medications, and mood stabilizers. Anticonvulsants and attention-deficit/hyperactivity disorder (ADHDS) medications (stimulants and non-stimulants) are not included at this time. In accordance with s. 409.912(51), F.S., the Health Plan shall ensure the following requirements are met:
(1) The prescriber must document the consent in the child’s medical record and provide the pharmacy with a signed attestation of the consent with the prescription.
(2) The prescriber must ensure completion of an appropriate attestation form.
(3) Sample consent/attestation forms that may be used and pharmacies may receive are located at the following link: WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract
(4) The completed form must be filed with the prescription (hardcopy of imaged) in the pharmacy and held for audit purposes for a minimum of six (6) years.
(5) Pharmacies may not add refills to old prescriptions to circumvent the need for an updated informed consent form.
(6) Every new prescription will require a new informed consent form.
(7) The informed consent forms do not replace prior authorization requirements for non-PDL medications or prior authorized antipsychotics for children and adolescents from birth through age seventeen (17).
Appears in 1 contract
Prescribed Drug Services. a. The Health Plan PSN shall provide those products and services associated with the dispensing of medicinal drugs pursuant to a valid prescription, as defined in Chapter 465, F.S. Prescribed Drug Services generally include all prescription drugs listed in the Agency’s Prescribed Drug List (“PDL”). See , as described in Section 409.91195, F.S. The PDL shall include at least two (2) products, when available, in each therapeutic class. Antiretroviral agents are not subject to the PDL. Pursuant to Section (See section 409.912(39), F.S., policy ) Policy requirements include, but are not limited to, the following:
(1) The Health Plan PSN shall make available those drugs and dosage forms listed in the PDL.
(2) The Health Plan PSN shall not arbitrarily deny or reduce the amount, duration or scope of prescriptions solely based on the Enrollee’s diagnosis, type of illness or condition. The Health Plan PSN may place appropriate limits on prescriptions based on criteria such as Medical Necessity, or for the purpose of utilization control, provided the Health Plan PSN reasonably expects said limits to achieve the purpose of the Prescribed Drug Services set forth in the Medicaid State Plan.
(3) The Health Plan PSN shall make available those drugs not on the PDL, when requested and approved, if the drugs on the PDL have been used in a step therapy sequence or when other documentation is provided.
(4) The Health Plan shall submit an updated PDL to the Agency annually, by October 1 of each Contract Year, and provide thirty (30) days written notice of any changes to the Bureau of Managed Health Care and Pharmacy Services.
b. The Health Plan PSN shall provide to Enrollees, who desire to quit smoking, one (1) course of nicotine replacement therapy, of twelve (12) weeks duration, or the manufacturer’s recommended duration, per year. The Health Plan PSN may use either nicotine transdermal patches or nicotine gum. (See the Medicaid Prescribed Drug Services Coverage, Limitations & Reimbursement Handbook.)
c. If the Health Plan PSN has authorization requirements for prescribed drug services, the Health Plan PSN shall comply with all aspects of the Settlement Agreement to Xxxxxxxxx, et. al.
Appears in 1 contract
Prescribed Drug Services. a. The Health Plan PSN shall provide those products and services associated with the dispensing of medicinal drugs pursuant to a valid prescription, as defined in Chapter 465, F.S. Prescribed Drug Services generally include all prescription drugs listed in the Agency’s Agency‘s Prescribed Drug List (“PDL”―PDL‖). See , as described in Section 409.91195, F.S. The PDL shall include at least two (2) products, when available, in each therapeutic class. Antiretroviral agents are not subject to the PDL. Pursuant to Section (See section 409.912(39), F.S., policy ) Policy requirements include, but are not limited to, the following:
(1) The Health Plan PSN shall make available those drugs and dosage forms listed in the PDL.
(2) The Health Plan PSN shall not arbitrarily deny or reduce the amount, duration or scope of prescriptions solely based on the Enrollee’s Enrollee‘s diagnosis, type of illness or condition. The Health Plan PSN may place appropriate limits on prescriptions based on criteria such as Medical Necessity, or for the purpose of utilization control, provided the Health Plan PSN reasonably expects said limits to achieve the purpose of the Prescribed Drug Services set forth in the Medicaid State Plan.
(3) The Health Plan PSN shall make available those drugs not on the PDL, when requested and approved, if the drugs on the PDL have been used in a step therapy sequence or when other documentation is provided.
(4) The Health Plan shall submit an updated PDL to the Agency annually, by October 1 of each Contract Year, and provide thirty (30) days written notice of any changes to the Bureau of Managed Health Care and Pharmacy Services.
b. The Health Plan PSN shall provide to Enrollees, who desire to quit smoking, one (1) course of nicotine replacement therapy, of twelve (12) weeks duration, or the manufacturer’s manufacturer‘s recommended duration, per year. The Health Plan PSN may use either nicotine transdermal patches or nicotine gum. (See the Medicaid Prescribed Drug Services Coverage, Limitations & Reimbursement Handbook.)
c. If the Health Plan PSN has authorization requirements for prescribed drug services, the Health Plan PSN shall comply with all aspects of the Settlement Agreement to Xxxxxxxxx, et. al.
Appears in 1 contract
Prescribed Drug Services. a. The Health Plan shall provide those products and services associated with the dispensing of medicinal drugs pursuant to a valid prescription, as defined in Chapter 465, F.S. Prescribed Drug Services drug services generally include all prescription drugs listed in the Agency’s Prescribed Preferred Drug List (“PDL”). See Section s. 409.91195, F.S. The Health Plan’s PDL shall include at least two (2) products, when available, in each therapeutic class. Antiretroviral agents are not subject to the PDL. Pursuant to Section s. 409.912(39), F.S., policy requirements include, but are not limited to, the following:
(1) The Health Plan shall make available those drugs and dosage forms listed in the its PDL.
(2) The Health Plan shall not arbitrarily deny or reduce the amount, duration or scope of prescriptions solely based on the Enrolleeenrollee’s diagnosis, type of illness or condition. The Health Plan may place appropriate limits on prescriptions based on criteria such as Medical Necessitymedical necessity, or for the purpose of utilization control, provided the Health Plan reasonably expects said limits to achieve the purpose of the Prescribed Drug Services prescribed drug services set forth in the Medicaid State Plan.
(3) The Health Plan shall make available those drugs not on the its PDL, when requested and approved, if the drugs on the PDL have been used in a step therapy sequence or when other medical documentation is provided.
(4) The Health Plan shall submit an updated a PDL that has been revised and approved by the Health Plan’s Pharmacy and Therapeutics (P&T) Committee to BMHC and the Agency annually, Bureau of Pharmacy Services by October 1 of each Contract Yearyear, and provide thirty forty-five (3045) days calendar days’ written notice of any changes to both bureaus. The attestation for this submission must include the Bureau dates for the P&T committee meeting(s) in which the PDL changes were discussed.
(a) The Health Plan shall keep on file, for Agency review, copies of Managed minutes and decision points from the P&T Committee meetings that support the choice of medications on the PDL. The Health Care Plan’s PDL shall be a listing of medications that the physician and Pharmacy pharmacist members of the Health Plan’s P&T Committee deem clinically appropriate and cost effective for the population enrolled in the Health Plan.
(b) See Section IV, Enrollee services, Item A., Enrollee Services, sub-item 13,. of this Attachment for enrollee notice requirements.
(c) The Health Plan shall notify providers who may prescribe or are currently prescribing a drug that the Health Plan is deleting from its PDL at least thirty (30) calendar days prior to the effective date of the change.
(d) If the Health Plan adopts the Medicaid PDL, the Health Plan shall be exempt from such reporting. Information on the Health Plan’s use of the PDL is in Attachment I and Attachment II, Exhibit 5, Covered Services.
(5) Antiretroviral agents are not subject to the PDL. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract
b. The Health Plan shall provide may delegate any or all functions to Enrollees, who desire to quit smoking, one (1) course of or more pharmacy benefits administrators (PBA). Before entering into a subcontract, the Health Plan shall work with the Agency’s fiscal agent.
c. The Health Plan shall continue the medication prescribed to the enrollee in a state mental health treatment facility for at least ninety (90) days after the facility discharges the enrollee, unless the Health Plan's prescribing psychiatrist, in consultation and agreement with the facility's prescribing physician, determines that the medications:
(1) Are not medically necessary; or
(2) Are potentially harmful to the enrollee.
d. The Health Plan shall provide nicotine replacement therapytherapy to enrollees who want to quit smoking as follows: The Health Plan shall use transdermal nicotine patches, of twelve gum or lozenges containing nicotine, and/or bupropion tablets (12generic for Zyban® when used in a smoking cessation program for no more than twenty-four (24) weeks durationper three-hundred sixty-five (365) days, or the manufacturer’s recommended durationrecommendation, per year. The Health Plan may use either nicotine transdermal patches or nicotine gumwhichever is less.
c. e. If the Health Plan has authorization requirements for prescribed drug services, the Health Plan shall comply with all aspects of the Settlement Agreement to Xxxxxxxxx, etet xx x. Xxxxxx (case number 02-20964 Civ-Gold/Xxxxxxxx) (HSA). alAn HSA situation arises when an enrollee attempts to fill a prescription at a participating pharmacy location and is unable to receive the prescription as a result of:
(1) An unreasonable delay in filling the prescription;
(2) A denial of the prescription;
(3) The reduction of a prescribed good or service; and/or
(4) The termination of a prescription.
f. The Health Plan shall ensure that its enrollees are receiving the functional equivalent of those goods and services received by fee-for-service Medicaid recipients in accordance with the HSA.
(1) The Health Plan shall maintain a log of all correspondence and communications from enrollees relating to the HSA ombudsman process. The ombudsman log shall contain, at a minimum, the enrollee’s name, address and telephone number and any other contact information, the reason for the participating pharmacy location’s denial (an unreasonable delay in filling a prescription, a denial of a prescription and/or the termination of a prescription), the pharmacy’s name (and store number, if applicable), the date of the call, a detailed explanation of the final resolution, and the name of the prescribed good or service. The ombudsman log report shall be submitted quarterly to BMHC, as required in Attachment II, Section XII, Reporting Requirements. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract
(2) The Health Plan’s enrollees are third party beneficiaries for this section of the Contract.
(3) The Health Plan shall conduct annual HSA surveys of no less than five percent (5%) of all participating pharmacy locations to ensure compliance with the HSA.
(a) The Health Plan may survey less than five percent (5%), with written approval from the Agency, if the Health Plan can show that the number of participating pharmacies it surveys is a statistically significant sample that adequately represents the pharmacies that have contracted with the Health Plan to provide pharmacy services.
(b) The Health Plan shall not include in the HSA survey any participating pharmacy location that the Health Plan found to be in complete compliance with the HSA requirements within the past twelve (12) months.
(c) The Health Plan shall require all participating pharmacy locations that fail any aspect of the HSA survey to undergo mandatory training within six (6) months and then be re-evaluated within one (1) month of the training to ensure that the pharmacy location is in compliance with the HSA.
(d) The Health Plan shall ensure that it complies with all aspects and surveying requirements set forth in Policy Transmittal 06-01, Xxxxxxxxx Settlement Requirements, an electronic copy of which can be found at:
(e) The Health Plan shall submit a report annually, by August 1 of each Contract year to BMHC, providing survey results following requirements in Attachment II, Section XII, Reporting Requirements.
(4) The Health Plan shall offer training to all new and existing participating pharmacy locations about the HSA requirements.
(5) The Health Plan shall ensure its PBA provides the following electronic message alerting the pharmacist to provide Medicaid recipients with the Xxxxxxxxx notice/pamphlet when coverage is rejected due to the drug not being on the Health Plan’s PDL:
g. The Health Plan shall cover the cost of a brand-name drug if the prescriber:
(1) Writes in his/her own handwriting on the valid prescription that the “Brand Name is Medically Necessary” (pursuant to s. 465.025, F.S.); and
(2) Submits a completed “Multisource Drug and Miscellaneous Prior Authorization” form to the Health Plan indicating that the enrollee has had an adverse reaction WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract to a generic drug or has had, in the prescriber’s medical opinion, better results when taking the brand-name drug.
h. Hemophilia factor-related drugs identified by the Agency for distribution through the Comprehensive Hemophilia Disease Management Program are reimbursed on a fee-for-service basis. During operation of the Comprehensive Hemophilia Disease Management Program, the Health Plan shall coordinate the care of its enrollees with Agency-approved organizations and shall not be responsible for the distribution of hemophilia-related drugs.
i. Capitated Health Plans shall submit behavioral health pharmacy encounter data to the BMHC secure file transfer protocol site in a format supplied by the Agency on an ongoing quarterly schedule, as specified in Attachment II, Section XII, Reporting Requirements and the Health Plan Report Guide.
j. Capitated Health Plans covering Reform populations shall submit a complete pharmacy drug list to the Agency‘s Reform choice counseling vendor annually by December 1, using the format provided in the Health Plan Report Guide referenced in Attachment II, Section XII, Reporting Requirements.
k. Capitated Health Plans may have a pharmacy lock-in program that conforms to the requirements in the Medicaid Prescribed Drug Services Coverage, Limitations and Reimbursement Handbook, provided it is submitted in writing to BMHC and approved by the Agency in advance of implementation.
l. If there is a dispute between the Agency and the drug manufacturer regarding federal drug rebates, the Health Plan shall assist the Agency in dispute resolution by providing information regarding claims and provider details. Failure to collect drug rebates due to the Health Plan’s failure to assist the Agency will result in the Agency’s recouping from the Health Plan any determined uncollected rebates.
m. The Health Plan shall require that prescriptions for psychotropic medication prescribed for an enrollee under the age of thirteen (13) be accompanied by the express written and informed consent of the enrollee’s parent or legal guardian. Psychotropic (psychotherapeutic) medications include antipsychotics, antidepressants, antianxiety medications, and mood stabilizers. Anticonvulsants and attention-deficit/hyperactivity disorder (ADHDS) medications (stimulants and non-stimulants) are not included at this time. In accordance with s. 409.912(51), F.S., the Health Plan shall ensure the following requirements are met:
(1) The prescriber must document the consent in the child’s medical record and provide the pharmacy with a signed attestation of the consent with the prescription.
(2) The prescriber must ensure completion of an appropriate attestation form.
(3) Sample consent/attestation forms that may be used and pharmacies may receive are located at the following link: xxxx://xxxx.xxxxxxxxx.xxx/Medicaid/Prescribed_Drug/med_resource.shtml. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract
(4) The completed form must be filed with the prescription (hardcopy of imaged) in the pharmacy and held for audit purposes for a minimum of six (6) years.
(5) Pharmacies may not add refills to old prescriptions to circumvent the need for an updated informed consent form.
(6) Every new prescription will require a new informed consent form.
(7) The informed consent forms do not replace prior authorization requirements for non-PDL medications or prior authorized antipsychotics for children and adolescents from birth through age seventeen (17).
Appears in 1 contract
Prescribed Drug Services. a. The Health Plan shall provide those products and services associated with the dispensing of medicinal drugs pursuant to a valid prescription, as defined in Chapter 465, F.S. Prescribed Drug Services generally include all prescription drugs listed in the Agency’s Prescribed Drug List (“PDL”). ,” See Section section 409.91195, F.S. F.S.), except for specific hemophilia-related drugs identified by the Agency to be reimbursed as Fee-for-Service beginning September 1, 2006. The PDL shall include at least two (2) products, when available, in each therapeutic class. Antiretroviral agents are not subject to the PDL. Pursuant PDL Policy requirements, pursuant to Section section 409.912(39), F.S., policy requirements include, but are not limited to, the following:
(1) The Health Plan shall make available those drugs and dosage forms listed in the PDL.
(2) The Health Plan shall not arbitrarily deny or reduce the amount, duration or scope of prescriptions solely based on the Enrollee’s diagnosis, type of illness or condition. The Health Plan may place appropriate limits on prescriptions based on criteria such as Medical Necessity, or for the purpose of utilization control, provided the Health Plan reasonably expects said limits to achieve the purpose of the Prescribed Drug Services set forth in the Medicaid State Plan.
(3) The Health Plan shall make available those drugs not on the PDL, when requested and approvedapprove, if the drugs on the PDL have been used in a step therapy sequence or when other documentation is provided.
(4) The Health Plan shall submit an updated PDL to the Agency annually, by October 1 of each Contract Year, and provide thirty (30) days written notice of any changes to the Bureau of Managed Health Care and Pharmacy Services.
b. The Health Plan shall provide to Enrollees, who desire to quit smoking, one (1) course of nicotine replacement therapy, of twelve (12) weeks duration, or the manufacturer’s recommended duration, per year. The Health Plan may use either nicotine transdermal patches or nicotine gum.
c. If the Health Plan has authorization requirements for prescribed drug services, the Health Plan shall comply with all aspects of the Settlement Agreement to XxxxxxxxxHxxxxxxxx, et. al. v. Xxxxxx (case number 02-20964 Civ-Gold/Sxxxxxxx) (HSA). An HSA situation arises when an Enrollee attempts to fill a prescription at a participating pharmacy location and is unable to receive his/her prescription as a result of:
(1) An unreasonable delay in filling the prescription;
(2) A denial of the prescription;
(3) The reduction of a prescribed good or service; and/or
(4) The termination of a prescription.
d. The Health Plan shall ensure that its Enrollees are receiving the functional equivalent of those goods and services received by non-Medicaid Reform Fee-for-Service Medicaid Recipients in accordance with the HSA.
(1) The Health Plan shall maintain a log of all correspondences and communications from Enrollees relating to the HSA Ombudsman process. The “Ombudsman Log” shall contain, at a minimum, the Enrollee’s name, address and telephone number and any other contact information, the reason for the participating pharmacy location’s denial (and unreasonable delay in filling a prescription, a denial of a prescription and/or the termination of a prescription), the pharmacy’s name (and store number, if applicable), the date of the call, a detailed explanation of the final resolution, and the name of prescribed good or service.
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Prescribed Drug Services. a. The Health Plan shall provide those products and services associated with the dispensing of medicinal drugs pursuant to a valid prescription, as defined in Chapter 465, F.S. Prescribed Drug Services generally include all prescription drugs listed in the Agency’s Prescribed Drug List (“PDL”). ,” See Section section 409.91195, F.S. F.S.), except for specific hemophilia-related drugs identified by the Agency to be reimbursed as Fee-for-Service beginning September 1, 2006. The PDL shall include at least two (2) products, when available, in each therapeutic class. Antiretroviral agents are not subject to the PDL. Pursuant PDL Policy requirements, pursuant to Section section 409.912(39), F.S., policy requirements include, but are not limited to, the following:
(1) The Health Plan shall make available those drugs and dosage forms listed in the PDL.
(2) The Health Plan shall not arbitrarily deny or reduce the amount, duration or scope of prescriptions solely based on the Enrollee’s diagnosis, type of illness or condition. The Health Plan may place appropriate limits on prescriptions based on criteria such as Medical Necessity, or for the purpose of utilization control, provided the Health Plan reasonably expects said limits to achieve the purpose of the Prescribed Drug Services set forth in the Medicaid State Plan.
(3) The Health Plan shall make available those drugs not on the PDL, when requested and approvedapprove, if the drugs on the PDL have been used in a step therapy sequence or when other documentation is provided.
(4) The Health Plan shall submit an updated PDL to the Agency annually, by October 1 of each Contract Year, and provide thirty (30) days written notice of any changes to the Bureau of Managed Health Care and Pharmacy Services.
b. The Health Plan shall provide to Enrollees, who desire to quit smoking, one (1) course of nicotine replacement therapy, of twelve (12) weeks duration, or the manufacturer’s recommended duration, per year. The Health Plan may use either nicotine transdermal patches or nicotine gum.
c. If the Health Plan has authorization requirements for prescribed drug services, the Health Plan shall comply with all aspects of the Settlement Agreement to Xxxxxxxxx, et. al. x. Xxxxxx (case number 02-20964 Civ-Gold/Xxxxxxxx) (HSA). An HSA situation arises when an Enrollee attempts to fill a prescription at a participating pharmacy location and is unable to receive his/her prescription as a result of:
(1) An unreasonable delay in filling the prescription;
(2) A denial of the prescription;
(3) The reduction of a prescribed good or service; and/or
(4) The termination of a prescription.
d. The Health Plan shall ensure that its Enrollees are receiving the functional equivalent of those goods and services received by non-Medicaid Reform Fee-for-Service Medicaid Recipients in accordance with the HSA.
(1) The Health Plan shall maintain a log of all correspondences and communications from Enrollees relating to the HSA Ombudsman process. The “Ombudsman Log” shall contain, at a minimum, the Enrollee’s name, address and telephone number and any other contact information, the reason for the participating pharmacy location’s denial (and unreasonable delay in filling a prescription, a denial of a prescription and/or the termination of a prescription), the pharmacy’s name (and store number, if applicable), the date of the call, a detailed explanation of the final resolution, and the name of prescribed good or service.
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