Prescription Drug Services. The Contractor shall provide pharmacy services to Members enrolled in the MississippiCAN Program. The Contractor shall comply with the Mississippi Pharmacy Practice Act and the Mississippi Board of Pharmacy rules and regulations. The Contractor is restricted from requiring Members to utilize a pharmacy that ships, mails, or delivers prescription drugs or devices. However, the Contractor may implement a mail-order pharmacy program in accordance with State and Federal law. The Contractor must use the most current version of the Medicaid Program Preferred Drug List (PDL), which is subject to periodic changes. The Contractor must use the Medicaid PDL developed by the Division or its Agent and may not develop and use its own PDL. The Contractor will be provided opportunities to offer feedback on the PDL to the Pharmacy and Therapeutics Committee, which is an advisory panel that conducts in-depth clinical evaluations and recommends appropriate drugs for preferred status on the PDL and/or drugs for Prior Authorization. The Executive Director of the Division has final authority on drugs with preferred status on the PDL and/or drugs for Prior Authorization. Refer to the Pharmacy Services page on the Division’s website for a current listing of prescription drugs on the PDL to ensure continuity of care for Members. The Contractor may approve drugs outside the PDL in accordance with Section 5.J, Prior Authorizations, of this Contract. The Contractor must cover and pay for a minimum of a three (3)-day emergency supply of prior authorized drugs until authorization is completed. The Contractor shall ensure that prescription drugs are prescribed and dispensed in accordance with medically accepted indications for uses and dosages. No payment may be made for services, procedures, supplies or drugs which are still in clinical trials and/or investigative or experimental in nature. The Contractor may consider exceptions to the criteria if there is sufficient documentation of stable therapy as reflected in ninety (90) calendar days of paid Medicaid claims. The Contractor is not authorized to negotiate rebates with drug companies for preferred pharmaceutical products. The Division or its Agent will negotiate rebate agreements. If the Contractor or its Subcontractor has an existing rebate agreement with a manufacturer, all Medicaid outpatient drug claims, including Provider-administered drugs, must be exempt from such rebate agreements. Please refer to Mississippi Administrative Code, Title 23, Part 203. The Contractor shall report information specified by the Division to enable the collection of rebates by the Division, as described in Section 10, Reporting Requirements, of this Contract. The Division processes Prior Authorization requests for prescription drugs within twenty- four (24) hours of receiving the request. The Contractor shall adhere to this time frame.
Appears in 2 contracts
Samples: www.medicaid.ms.gov, medicaid.ms.gov
Prescription Drug Services. The Contractor shall comply with all requirements found in the Social Security Act section 1927 and all changes made to the Covered Outpatient Drug Section of the Patient Protection and Affordable Care Act (PPACA) found in 42 C.F.R. Part 447 [CMS 2345-FC]. The Contractor shall provide pharmacy services to Members enrolled in the MississippiCAN ProgramCHIP. The Contractor shall comply with the Mississippi Pharmacy Practice Act (Miss. Code Xxx. § 73- 21-71, et. seq.) and the Mississippi Board of Pharmacy rules and regulations. The Contractor is restricted from requiring Members to utilize a pharmacy that ships, mails, or delivers prescription drugs or devices. However, The contractor shall not reject claims for any drugs in a retail pharmacy for the Contractor may implement a mail-purpose of redirecting prescriptions to the contractor’s mail order pharmacy program in accordance with State and Federal lawand/or contracted specialty pharmacy. The Contractor must use the most current version of the Mississippi Division of Medicaid Program Universal Preferred Drug List (PDL), ) which is subject to periodic changes. The Contractor must use the Medicaid PDL and prior authorization criteria developed by the Division or its Agent and may not develop and use its own PDL. The Contractor will be provided opportunities to offer feedback on the PDL to the Pharmacy and Therapeutics Committee, which is an advisory panel that conducts in-depth clinical evaluations and recommends appropriate drugs for preferred status on the PDL and/or drugs for Prior AuthorizationDivision. The Executive Director of the Division has final authority on drugs with preferred status on the PDL and/or drugs for Prior Authorization. Refer The Contractor shall not promote any preferred drugs over other preferred drugs. The Contractor must refer to the Division’s website, specifically the Pharmacy Services page on the Division’s website Page, for a current listing of prescription drugs on the PDL to ensure continuity of care for Members. Pursuant to 438.10(i), the Contractor must make available in paper and electronic form the following Preferred Drug List information: which medications are covered (generic and name brand), what tier each medication is on, if applicable, and the information must be made available on the Contractor’s website. Benefits will be provided for over the counter medications which are listed on the MS Medicaid Covered Over-the-Counter (OTC) Drugs list and obtained with a prescription. The Contractor shall establish a unique BIN / PCN number for the processing of Mississippi Medicaid CHIP Members pharmacy claims for the purpose of separating the Contractor’s third party private pharmacy Provider claims from the Medicaid CHIP claims. The remittance advice statements must adhere to industry standards and be in a user-friendly format and approved by the Division and as defined by the Division. The Contractor shall not keep a spread between what the Contractor and its PBM pay and what any participating pharmacy receives on any prescription drug claim dispensed to a Member. The Contractor’s reimbursement methodology for the PBM must be based on the actual amount paid by the PBM to a pharmacy for dispensing and ingredient costs. However, this prohibition on the industry practice known as “spread pricing” is not intended to prohibit the Contractor from paying the PBM reasonable administrative and transactional costs for services. The Contractor must ensure its subcontracted PBM does not directly or indirectly charge or hold a pharmacist or pharmacy responsible for a fee for any step of or component related to the claim adjudication process. The Contractor shall provide the Division’s Office of Pharmacy electronic access/viewing rights of the contracted Pharmacy Benefits Manager’s real-time pharmacy point-of-sale claims system and testing rights in the PBM’s pharmacy point-of-sale claims testing environment. The Contractor must include a written description of assurances and procedures policies under the proposed PBM Subcontract such as an independent audit to ensure no conflicts of interest exist and ensure the confidentiality of proprietary information. The Contractor must provide a plan documenting how it will monitor these Subcontractors. The assurances and procedures policies must be submitted for the Division’s review 30 days prior to initiating any PBM Subcontract. The Contractor must conduct a prior authorization program that complies with the requirements of section 1927(d)(5) of the Act and as defined by the Division. The Contractor may approve drugs outside the PDL in accordance with Section 5.J5.I, Prior Authorizations, of this Contract. The Division processes Prior Authorization requests for prescription drugs within twenty-four (24) hours of receiving the request. The Contractor shall adhere to this time frame. The Contractor must cover and pay for a minimum of a three (3)-day emergency supply of prior authorized drugs until authorization is completed. The Contractor shall ensure that prescription drugs are prescribed and dispensed in accordance with medically accepted indications for uses and dosages. No payment may be made for services, procedures, supplies or drugs which are still in clinical trials and/or investigative or experimental in nature. The dispensing limits for any drug may be restricted to a thirty (30)-day supply at one time except for those drugs listed on the 90 day list and those defined in Administrative Code Title 23 found on the Division’s website. A Member must be allowed to obtain an early refill of a prescription drug under certain circumstances, such as change of dosage during the course of treatment, for lost or destroyed medication, or when the Member is going on vacation. The Member or his/her representative may be required to contact the Contractor may consider exceptions to obtain authorization for any early refill or advance supply of a medication. The Division does not collect CHIP drug rebates. However, the Contractors must report any rebates collected to the criteria if there is sufficient documentation of stable therapy as reflected in ninety (90) calendar days of paid Division. The Division must be informed prior to any and all Medicaid claimspharmacy audits. The Contractor is not authorized to negotiate rebates must complete all audits of a Provider clean claim within a time frame consistent with drug companies for preferred pharmaceutical products. The Division or its Agent will negotiate rebate agreementsstate law. If the audit indicates that the Contractor or its Subcontractor has an existing rebate agreement with is due a manufacturerrefund from the Provider, all Medicaid outpatient drug claims, including Provider-administered drugs, the Contractor must be exempt from such rebate agreements. Please refer to Mississippi Administrative Code, Title 23, Part 203. The Contractor shall report information specified by send the Division to enable Provider written notice of the collection of rebates by the Division, as described in Section 10, Reporting Requirements, of this Contract. The Division processes Prior Authorization requests basis and specific reasons for prescription drugs within twenty- four (24) hours of receiving the request. The Contractor shall adhere must give the Provider an opportunity to this time frame.appeal.
Appears in 1 contract
Samples: Contract
Prescription Drug Services. The Contractor shall comply with all requirements found in the Social Security Act section 1927 and all changes made to the Covered Outpatient Drug Section of the Patient Protection and Affordable Care Act (PPACA) found in 42 C.F.R. Part 447 [CMS 2345-FC]. The Contractor shall provide pharmacy services to Members enrolled in the MississippiCAN ProgramCHIP. The Contractor shall comply with the Mississippi Pharmacy Practice Act (Miss. Code Xxx. § 73- 21-71, et. seq.) and the Mississippi Board of Pharmacy rules and regulations. The Contractor is restricted from requiring Members to utilize a pharmacy that ships, mails, or delivers prescription drugs or devices. However, The contractor shall not reject claims for any drugs in a retail pharmacy for the Contractor may implement a mail-purpose of redirecting prescriptions to the contractor’s mail order pharmacy program in accordance with State and Federal lawand/or contracted specialty pharmacy. The Contractor must use the most current version of the Mississippi Division of Medicaid Program Universal Preferred Drug List (PDL), ) which is subject to periodic changes. The Contractor must use the Medicaid PDL and prior authorization criteria developed by the Division or its Agent and may not develop and use its own PDL. The Contractor will be provided opportunities to offer feedback on the PDL to the Pharmacy and Therapeutics Committee, which is an advisory panel that conducts in-depth clinical evaluations and recommends appropriate drugs for preferred status on the PDL and/or drugs for Prior AuthorizationOffice of Pharmacy’s Director. The Executive Director of the Division has final authority on drugs with preferred status on the PDL and/or drugs for Prior Authorization. Refer The Contractor shall not promote any preferred drugs over other preferred drugs. The Contractor must refer to the Division’s website, specifically the Pharmacy Services page on the Division’s website Page, for a current listing of prescription drugs on the PDL to ensure continuity of care for Members. Pursuant to 438.10(i), the Contractor must make available in paper and electronic form the following Preferred Drug List information: which medications are covered (generic and name brand), what tier each medication is on, if applicable, and the information must be made available on the Contractor’s website. Benefits will be provided for over the counter medications which are listed on the MS Medicaid Covered Over-the-Counter (OTC) Drugs list and obtained with a prescription. The Contractor shall establish a unique BIN / PCN number for the processing of Mississippi Medicaid CHIP Members pharmacy claims for the purpose of separating the Contractor’s third party private pharmacy Provider claims from the Medicaid CHIP claims. The remittance advice statements must adhere to industry standards and be in a user-friendly format and approved by the Division and as defined by the Division. The Contractor’s reimbursement methodology used by the Pharmacy Benefits Manager (“PBM”) must be based on the actual amount paid by the PBM to a pharmacy for the dispensing fee and the ingredient cost. The Contractor must ensure its subcontracted PBM does not directly or indirectly charge or hold a pharmacist or pharmacy responsible for a fee for any step of or component related to the claim adjudication process. The Contractor shall provide the Division’s Office of Pharmacy electronic access/viewing rights of the contracted Pharmacy Benefits Manager’s real-time pharmacy point-of-sale claims system and testing rights in the PBM’s pharmacy point-of-sale claims testing environment. The Contractor/Subcontractor must follow the Division’s current reimbursement methodology to reimburse pharmacy Providers for pharmacy point of sale claims. The Contractor must include a written description of assurances and procedures policies under the proposed PBM Subcontract such as an independent audit to ensure no conflicts of interest exist and ensure the confidentiality of proprietary information. The Contractor must provide a plan documenting how it will monitor these Subcontractors. The assurances and procedures policies must be submitted for the Division’s review 30 days prior to initiating any PBM Subcontract. The Contractor must conduct a prior authorization program that complies with the requirements of section 1927(d)(5) of the Act and as defined by the Division. The Contractor may approve drugs outside the PDL in accordance with Section 5.J5.I, Prior Authorizations, of this Contract. The Division processes Prior Authorization requests for prescription drugs within twenty-four (24) hours of receiving the request. The Contractor shall adhere to this time frame. The Contractor must cover and pay for a minimum of a three (3)-day emergency supply of prior authorized drugs until authorization is completed. The Contractor shall ensure that prescription drugs are prescribed and dispensed in accordance with medically accepted indications for uses and dosages. No payment may be made for services, procedures, supplies or drugs which are still in clinical trials and/or investigative or experimental in nature. The dispensing limits for any drug may be restricted to a thirty (30)-day supply at one time except for those drugs listed on the 90 day list and those defined in Administrative Code Title 23 found on the Division’s website. A Member must be allowed to obtain an early refill of a prescription drug under certain circumstances, such as change of dosage during the course of treatment, for lost or destroyed medication, or when the Member is going on vacation. The Member or his/her representative may be required to contact the Contractor may consider exceptions to obtain authorization for any early refill or advance supply of a medication. The Division does not collect CHIP drug rebates. However, the Contractors must report any rebates collected to the criteria if there is sufficient documentation of stable therapy as reflected in ninety (90) calendar days of paid Division. The Division must be informed prior to any and all Medicaid claimspharmacy audits. The Contractor is not authorized to negotiate rebates with drug companies for preferred pharmaceutical products. The Division or its Agent will negotiate rebate agreementsmust complete all audits of a Provider claim no later than one year after receipt of a clean claim. If the audit indicates that the Contractor or its Subcontractor is due a refund from the Provider, the Contractor must send the Provider written notice of the basis and specific reasons for the request, the Contractor must give the Provider an opportunity to Appeal and may not attempt to recover the payment until the Provider has an existing rebate agreement with a manufacturer, exhausted all Medicaid outpatient drug claims, including Provider-administered drugs, must be exempt from such rebate agreements. Please refer to Mississippi Administrative Code, Title 23, Part 203. The Contractor shall report information specified by Appeals rights And the Division to enable has approved of the collection of rebates by the Division, as described in Section 10, Reporting Requirements, of this Contract. The Division processes Prior Authorization requests for prescription drugs within twenty- four (24) hours of receiving the request. The Contractor shall adhere to this time frame.findings.
Appears in 1 contract
Samples: Contract
Prescription Drug Services. The Contractor shall provide pharmacy services to Members enrolled in the MississippiCAN ProgramCHIP. The Contractor shall comply with the Mississippi Pharmacy Practice Act (Miss. Code Xxx. § 73-21-71, et. seq.) and the Mississippi Board of Pharmacy rules and regulations. The Contractor is restricted from requiring Members to utilize a pharmacy that ships, mails, or delivers prescription drugs or devices. However, the Contractor may implement a mail-order pharmacy program in accordance with State and Federal law. The Contractor must use the most current version of the Medicaid Program Preferred Drug List (PDL), which is subject to periodic changes. The Contractor must use the Medicaid PDL developed by the Division DOM or its Agent and may not develop and use its own PDL. The Contractor will be provided opportunities to offer feedback on the PDL to the Pharmacy and Therapeutics Committee, which is an advisory panel that conducts in-in- depth clinical evaluations and recommends appropriate drugs for preferred status on the PDL and/or drugs for Prior Authorization. The Executive Director of the Division DOM has final authority on drugs with preferred status on the PDL and/or drugs for Prior Authorization. Benefits will be provided for select over the counter medications purchased with a prescription, including analgesics, vitamins, nicotine replacement, topical formulations, gastrointestinal agents, and cough/cold medications. Refer to the Pharmacy Services page on the DivisionDOM’s website for a current listing of prescription drugs on the PDL to ensure continuity of care for Members. The Contractor may approve drugs outside the PDL in accordance with Section 5.J5.H, Prior Authorizations, of this Contract. The Contractor must cover and pay for a minimum of a three (3)-day emergency supply of prior authorized drugs until authorization is completed. The Contractor shall ensure that prescription drugs are prescribed and dispensed in accordance with medically accepted indications for uses and dosages. No payment may be made for services, procedures, supplies or drugs which are still in clinical trials and/or investigative or experimental in nature. The Contractor may consider exceptions to the criteria if there is sufficient documentation of stable therapy as reflected in ninety (90) calendar days of paid Medicaid claims. The Contractor is not authorized to shall negotiate rebates with drug companies for preferred pharmaceutical productsproducts and submit data to DOM regarding the amount of rebates received for Members specific to CHIP semi-annually, in a format to be specified by DOM. The Division or its Agent will negotiate rebate agreementsdispensing limits for any drug may be restricted to a thirty (30)-day supply at one time. If the Contractor or its Subcontractor has an existing rebate agreement with a manufacturer, all Medicaid outpatient drug claims, including Provider-administered drugs, A Member must be exempt from allowed to obtain an early refill of a prescription drug under certain circumstances, such rebate agreements. Please refer to Mississippi Administrative Codeas change of dosage during the course of treatment, Title 23for lost or destroyed medication, Part 203or when the Member is going on vacation. The Member or his/her representative may be required to contact Contractor shall report information specified by the Division to enable the collection obtain authorization for any early refill or advance supply of rebates by the Division, as described in Section 10, Reporting Requirements, of this Contracta medication. The Division DOM processes Prior Authorization requests for prescription drugs within twenty- four (24) hours of receiving the request. The Contractor shall adhere to this time frame.twenty-four
Appears in 1 contract
Samples: www.medicaid.ms.gov
Prescription Drug Services. The Contractor shall comply with all requirements found in the Social Security Act section 1927 and all changes made to the Covered Outpatient Drug Section of the Patient Protection and Affordable Care Act (PPACA) found in 42 C.F.R. Part 447 [CMS 2345-FC]. The Contractor shall provide pharmacy services to Members enrolled in the MississippiCAN ProgramCHIP. The Contractor shall comply with the Mississippi Pharmacy Practice Act (Miss. Code Xxx. § 73- 21-71, et. seq.) and the Mississippi Board of Pharmacy rules and regulations. The Contractor is restricted from requiring Members to utilize a pharmacy that ships, mails, or delivers prescription drugs or devices. However, The contractor shall not reject claims for any drugs in a retail pharmacy for the Contractor may implement a mail-purpose of redirecting prescriptions to the contractor’s mail order pharmacy program in accordance with State and Federal lawand/or contracted specialty pharmacy. The Contractor must use the most current version of the Mississippi Division of Medicaid Program Universal Preferred Drug List (PDL), ) which is subject to periodic changes. The Contractor must use the Medicaid PDL and prior authorization criteria developed by the Division or its Agent and may not develop and use its own PDL. The Contractor will be provided opportunities to offer feedback on the PDL to the Pharmacy and Therapeutics Committee, which is an advisory panel that conducts in-depth clinical evaluations and recommends appropriate drugs for preferred status on the PDL and/or drugs for Prior AuthorizationOffice of Pharmacy’s Director. The Executive Director of the Division has final authority on drugs with preferred status on the PDL and/or drugs for Prior Authorization. Refer The Contractor shall not promote any preferred drugs over other preferred drugs. The Contractor must refer to the Division’s website, specifically the Pharmacy Services page on the Division’s website Page, for a current listing of prescription drugs on the PDL to ensure continuity of care for Members. Pursuant to 438.10(i), the Contractor must make available in paper and electronic form the following Preferred Drug List information: which medications are covered (generic and name brand), what tier each medication is on, if applicable, and the information must be made available on the Contractor’s website. Benefits will be provided for over the counter medications which are listed on the MS Medicaid Covered Over-the-Counter (OTC) Drugs list and obtained with a prescription. The Contractor shall establish a unique BIN / PCN number for the processing of Mississippi Medicaid CHIP Members pharmacy claims for the purpose of separating the Contractor’s third party private pharmacy Provider claims from the Medicaid CHIP claims. The remittance advice statements must adhere to industry standards and be in a user-friendly format and approved by the Division and as defined by the Division. The Contractor’s reimbursement methodology used by the Pharmacy Benefits Manager (“PBM”) must be based on the actual amount paid by the PBM to a pharmacy for the dispensing fee and the ingredient cost. The Contractor must ensure its subcontracted PBM does not directly or indirectly charge or hold a pharmacist or pharmacy responsible for a fee for any step of or component related to the claim adjudication process. The Contractor shall provide the Division’s Office of Pharmacy electronic access/viewing rights of the contracted Pharmacy Benefits Manager’s real-time pharmacy point-of-sale claims system and testing rights in the PBM’s pharmacy point-of-sale claims testing environment. The Contractor/Subcontractor must follow the Division’s current reimbursement methodology to reimburse pharmacy Providers for pharmacy point of sale claims. The Contractor must include a written description of assurances and procedures policies under the proposed PBM Subcontract such as an independent audit to ensure no conflicts of interest exist and ensure the confidentiality of proprietary information. The Contractor must provide a plan documenting how it will monitor these Subcontractors. The assurances and procedures policies must be submitted for the Division’s review 30 days prior to initiating any PBM Subcontract. The Contractor must conduct a prior authorization program that complies with the requirements of section 1927(d)(5) of the Act and as defined by the Division. The Contractor may approve drugs outside the PDL in accordance with Section 5.J5.I, Prior Authorizations, of this Contract. The Division processes Prior Authorization requests for prescription drugs within twenty-four (24) hours of receiving the request. The Contractor shall adhere to this time frame. The Contractor must cover and pay for a minimum of a three (3)-day emergency supply of prior authorized drugs until authorization is completed. The Contractor shall ensure that prescription drugs are prescribed and dispensed in accordance with medically accepted indications for uses and dosages. No payment may be made for services, procedures, supplies or drugs which are still in clinical trials and/or investigative or experimental in nature. The dispensing limits for any drug may be restricted to a thirty (30)-day supply at one time except for those drugs listed on the 90 day list and those defined in Administrative Code Title 23 found on the Division’s website. A Member must be allowed to obtain an early refill of a prescription drug under certain circumstances, such as change of dosage during the course of treatment, for lost or destroyed medication, or when the Member is going on vacation. The Member or his/her representative may be required to contact the Contractor may consider exceptions to obtain authorization for any early refill or advance supply of a medication. The Division does not collect CHIP drug rebates. However, the Contractors must report any rebates collected to the criteria if there is sufficient documentation of stable therapy as reflected in ninety (90) calendar days of paid Division. The Division must be informed prior to any and all Medicaid claimspharmacy audits. The Contractor is not authorized to negotiate rebates with drug companies for preferred pharmaceutical products. The Division or its Agent will negotiate rebate agreementsmust complete all audits of a Provider claim no later than one year after receipt of a clean claim. If the audit indicates that the Contractor or its Subcontractor is due a refund from the Provider, the Contractor must send the Provider written notice of the basis and specific reasons for the request, the Contractor must give the Provider an opportunity to Appeal and may not attempt to recover the payment until the Provider has an existing rebate agreement with a manufacturer, exhausted all Medicaid outpatient drug claims, including Provider-administered drugs, must be exempt from such rebate agreements. Please refer to Mississippi Administrative Code, Title 23, Part 203. The Contractor shall report information specified by Appeals rights And the Division to enable has approved of the collection of rebates by the Division, as described in Section 10, Reporting Requirements, of this Contract. The Division processes Prior Authorization requests for prescription drugs within twenty- four (24) hours of receiving the request. The Contractor shall adhere to this time framefindings.
Appears in 1 contract
Samples: Contract
Prescription Drug Services. The Contractor shall comply with all requirements found in the Social Security Act section 1927 and all changes made to the Covered Outpatient Drug Section of the Patient Protection and Affordable Care Act (PPACA) found in 42 C.F.R. Part 447 [CMS 2345-FC]. The Contractor shall provide pharmacy services to Members enrolled in the MississippiCAN ProgramCHIP. The Contractor shall comply with the Mississippi Pharmacy Practice Act (Miss. Code Xxx. § 73- 21-71, et. seq.) and the Mississippi Board of Pharmacy rules and regulations. The Contractor is restricted from requiring Members to utilize a pharmacy that ships, mails, or delivers prescription drugs or devices. However, The contractor shall not reject claims for any drugs in a retail pharmacy for the Contractor may implement a mail-purpose of redirecting prescriptions to the contractor’s mail order pharmacy program in accordance with State and Federal lawand/or contracted specialty pharmacy. The Contractor must use the most current version of the Mississippi Division of Medicaid Program Universal Preferred Drug List (PDL), ) which is subject to periodic changes. The Contractor must use the Medicaid PDL and prior authorization criteria developed by the Division or its Agent and may not develop and use its own PDL. The Contractor will be provided opportunities to offer feedback on the PDL to the Pharmacy and Therapeutics Committee, which is an advisory panel that conducts in-depth clinical evaluations and recommends appropriate drugs for preferred status on the PDL and/or drugs for Prior AuthorizationDivision. The Executive Director of the Division has final authority on drugs with preferred status on the PDL and/or drugs for Prior Authorization. Refer The Contractor shall not promote any preferred drugs over other preferred drugs. The Contractor must refer to the Division’s website, specifically the Pharmacy Services page on the Division’s website Page, for a current listing of prescription drugs on the PDL to ensure continuity of care for Members. Pursuant to 438.10(i), the Contractor must make available in paper and electronic form the following Preferred Drug List information: which medications are covered (generic and name brand), what tier each medication is on, if applicable, and the information must be made available on the Contractor’s website. Benefits will be provided for over the counter medications which are listed on the MS Medicaid Covered Over-the-Counter (OTC) Drugs list and obtained with a prescription. The Contractor shall establish a unique BIN / PCN number for the processing of Mississippi Medicaid CHIP Members pharmacy claims for the purpose of separating the Contractor’s third party private pharmacy Provider claims from the Medicaid CHIP claims. The remittance advice statements must adhere to industry standards and be in a user-friendly format and approved by the Division and as defined by the Division. The Contractor shall not keep a spread between what the Contractor and its PBM pay and what any participating pharmacy receives on any prescription drug claim dispensed to a Member. The Contractor’s reimbursement methodology for the PBM must be based on the actual amount paid by the PBM to a pharmacy for dispensing and ingredient costs. However, this prohibition on the industry practice known as “spread pricing” is not intended to prohibit the Contractor from paying the PBM reasonable administrative and transactional costs for services. The Contractor must ensure its subcontracted PBM does not directly or indirectly charge or hold a pharmacist or pharmacy responsible for a fee for any step of or component related to the claim adjudication process. The Contractor shall provide the Division’s Office of Pharmacy electronic access/viewing rights of the contracted Pharmacy Benefits Manager’s real-time pharmacy point-of-sale claims system and testing rights in the PBM’s pharmacy point-of-sale claims testing environment. The Contractor must include a written description of assurances and procedures policies under the proposed PBM Subcontract such as an independent audit to ensure no conflicts of interest exist and ensure the confidentiality of proprietary information. The Contractor must provide a plan documenting how it will monitor these Subcontractors. The assurances and procedures policies must be submitted for the Division’s review 30 days prior to initiating any PBM Subcontract. The Contractor must conduct a prior authorization program that complies with the requirements of section 1927(d)(5) of the Act and as defined by the Division. The Contractor may approve drugs outside the PDL in accordance with Section 5.J5.I, Prior Authorizations, of this Contract. The Division processes Prior Authorization requests for prescription drugs within twenty-four (24) hours of receiving the request. The Contractor shall adhere to this time frame. The Contractor must cover and pay for a minimum of a three (3)-day emergency supply of prior authorized drugs until authorization is completed. The Contractor shall ensure that prescription drugs are prescribed and dispensed in accordance with medically accepted indications for uses and dosages. No payment may be made for services, procedures, supplies or drugs which are still in clinical trials and/or investigative or experimental in nature. The dispensing limits for any drug may be restricted to a thirty (30)-day supply at one time except for those drugs listed on the 90 day list and those defined in Administrative Code Title 23 found on the Division’s website. A Member must be allowed to obtain an early refill of a prescription drug under certain circumstances, such as change of dosage during the course of treatment, for lost or destroyed medication, or when the Member is going on vacation. The Member or his/her representative may be required to contact the Contractor may consider exceptions to obtain authorization for any early refill or advance supply of a medication. The Division does not collect CHIP drug rebates. However, the Contractors must report any rebates collected to the criteria if there is sufficient documentation of stable therapy as reflected in ninety (90) calendar days of paid Division. The Division must be informed prior to any and all Medicaid claimspharmacy audits. The Contractor is not authorized to negotiate rebates must complete all audits of a Provider clean claim within a time frame consistent with drug companies for preferred pharmaceutical products. The Division or its Agent will negotiate rebate agreementsstate law. If the audit indicates that the Contractor or its Subcontractor has an existing rebate agreement with is due a manufacturerrefund from the Provider, all Medicaid outpatient drug claims, including Provider-administered drugs, the Contractor must be exempt from such rebate agreements. Please refer to Mississippi Administrative Code, Title 23, Part 203. The Contractor shall report information specified by send the Division to enable Provider written notice of the collection of rebates by the Division, as described in Section 10, Reporting Requirements, of this Contract. The Division processes Prior Authorization requests basis and specific reasons for prescription drugs within twenty- four (24) hours of receiving the request. The Contractor shall adhere must give the Provider an opportunity to this time frameappeal.
Appears in 1 contract
Samples: Contract
Prescription Drug Services. The Contractor shall provide pharmacy services to Members enrolled in the MississippiCAN ProgramCHIP. The Contractor shall comply with the Mississippi Pharmacy Practice Act and the Mississippi Board of Pharmacy rules and regulations. The Contractor is restricted from requiring Members to utilize a pharmacy that ships, mails, or delivers prescription drugs or devices. However, the Contractor may implement a mail-order pharmacy program in accordance with State and Federal law. The Contractor must use the most current version of the Medicaid Program Preferred Drug List (PDL), which is subject to periodic changes. The Contractor must use the Medicaid PDL developed by the Division DOM or its Agent and may not develop and use its own PDL. The Contractor will be provided opportunities to offer feedback on the PDL to the Pharmacy and Therapeutics Committee, which is an advisory panel that conducts in-in- depth clinical evaluations and recommends appropriate drugs for preferred status on the PDL and/or drugs for Prior Authorization. The Executive Director of the Division DOM has final authority on drugs with preferred status on the PDL and/or drugs for Prior Authorization. Benefits will be provided for select over the counter medications purchased with a prescription, including analgesics, vitamins, nicotine replacement, topical formulations, gastrointestinal agents, and cough/cold medications. Refer to the Pharmacy Services page on the DivisionDOM’s website for a current listing of prescription drugs on the PDL to ensure continuity of care for Members. The Contractor may approve drugs outside the PDL in accordance with Section 5.J5.H, Prior Authorizations, of this Contract. The Contractor must cover and pay for a minimum of a three (3)-day emergency supply of prior authorized drugs until authorization is completed. The Contractor shall ensure that prescription drugs are prescribed and dispensed in accordance with medically accepted indications for uses and dosages. No payment may be made for services, procedures, supplies or drugs which are still in clinical trials and/or investigative or experimental in nature. The Contractor may consider exceptions to the criteria if there is sufficient documentation of stable therapy as reflected in ninety (90) calendar days of paid Medicaid claims. The Contractor is not authorized to shall negotiate rebates with drug companies for preferred pharmaceutical productsproducts and submit data to DOM regarding the amount of rebates received for Members specific to CHIP semi-annually, in a format to be specified by DOM. The Division or its Agent will negotiate rebate agreementsdispensing limits for any drug may be restricted to a thirty (30)-day supply at one time. If the Contractor or its Subcontractor has an existing rebate agreement with a manufacturer, all Medicaid outpatient drug claims, including Provider-administered drugs, A Member must be exempt from allowed to obtain an early refill of a prescription drug under certain circumstances, such rebate agreements. Please refer to Mississippi Administrative Codeas change of dosage during the course of treatment, Title 23for lost or destroyed medication, Part 203or when the Member is going on vacation. The Member or his/her representative may be required to contact Contractor shall report information specified by the Division to enable the collection obtain authorization for any early refill or advance supply of rebates by the Division, as described in Section 10, Reporting Requirements, of this Contracta medication. The Division DOM processes Prior Authorization requests for prescription drugs within twenty- four (24) hours of receiving the request. The Contractor shall adhere to this time frame.twenty-four
Appears in 1 contract
Samples: www.medicaid.ms.gov
