Step Therapy Protocols. Contractor may provide a step therapy program, pursuant to which limitations on drug coverage may be established for categories of drugs that are not otherwise covered by or included in the plan. Such coverage limitations are defined and established based upon Board’s written approval. Claims for these drugs will be rejected if the coverage requirements established by Board’s applicable step therapy protocols are not satisfied. Step therapy will involve an automated Prior Authorization process developed by the Contractor and implemented upon Board’s written approval regarding certain drugs and drug classes. For Board-selected Drug Products, the claims system will search the claims history to determine if Board’s criteria for coverage have been met. The Board acknowledges that the step therapy program is an automated, non-discretionary processing technique intended to provide better management of the Board’s drug benefits based upon objective criteria approved by Board. Contractor shall not undertake, and is not required, to determine medical necessity or appropriateness of therapy determinations, to make diagnoses, or to substitute Contractor's judgment for the professional judgment and responsibility of the physician.
Step Therapy Protocols. The CONTRACTOR may provide a step therapy program, pursuant to which limitations on drug coverage may be established for categories of drugs that are not otherwise covered by or included in the plan. Such coverage limitations are defined and established based upon agreement between the CONTRACTOR and the DEPARTMENT, on behalf of the BOARD. Claims for these drugs will be rejected if the coverage requirements established by applicable step therapy protocols are not satisfied. Step therapy will involve an automated PRIOR AUTHORIZATION process developed by the CONTRACTOR and implemented upon agreement with the DEPARTMENT regarding certain drugs and drug classes. For selected PRODUCTS, the claims system will search the claims history to determine if step-therapy criteria for coverage have been met. The BOARD acknowledges that the step therapy program is an automated, non-discretionary processing technique intended to provide better management of the BOARD’s PRESCRIPTION DRUG PLAN based on objective criteria agreed to with the DEPARTMENT, on behalf of the BOARD. The CONTRACTOR shall not undertake, and is not required, to determine medical necessity or appropriateness of therapy determinations, to make diagnoses, or to substitute the CONTRACTOR’s judgment for the professional judgment and responsibility of the prescribing physician. The CONTRACTOR is required to implement and report on DEPARTMENT programs designed to manage cost. Programs are subject to change, as determined by the DEPARTMENT, to better serve the needs of the PHARMACY BENEFIT PLAN PARTICIPANTS. The current DEPARTMENT programs are:
