Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations. The Contractor shall comply with the requirements of IC 12-15-35.5-3 in establishing prescribing limits to mental health drugs. For any drugs which require prior authorization, the Contractor shall provide a response by telephone or other telecommunication device within twenty-four (24) hours of a request for prior authorization. Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour supply of a covered outpatient prescription drug in an emergency situation as required under 42 U.S.C 1396r- 8(d)(5)(B). The Contractor shall employ an automated system for approval of a seventy-two (72) hour emergency supply of a restricted drug. The automated system shall allow the pharmacist to dispense the seventy-two (72) hour supply and then follow-up with the Contractor or provider the next business day. The Contractor, implementing a unified PDL, shall implement prior authorization approved for all plans, by the DUR Board. The Contractor shall participate in the development and recommendation of PA criteria brought before the DUR Board. If it elects to utilize its own PA process, the Contractor may require prior authorization requirements, such as general member information, a justification of need for drug related to the medical needs of the member and a planned course of treatment, if applicable, as related to the number drug provided and duration of treatment. The Contractor will be required to have a process in place to allow drugs that are medically necessary but not included on the formulary to be accessed by members. The Contractor will be required to accept prior authorization requests via telephone, fax, web-based system, or in writing. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed and implemented PA criteria will be displayed, in a common format, alongside fee for service and other Contractor criteria. Additionally, the Contractor shall implement retrospective drug use review to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists and individuals receiving benefits, or associated with specific drugs or groups of drugs.
Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations. For any drugs which require prior authorization, the Contractor shall provide a response by telephone or other telecommunication device within twenty -four
Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations. For any drugs which require prior authorization, the Contractor shall provide a response by telephone or other telecommunication device within twenty-four (24) hours of a request for prior authorization. Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour supply of a covered outpatient prescription drug in an emergency situation as required under 42 U.S.C 1396r- 8(d)(5)(B). The Contractor shall comply with the requirements of IC 12-15- 35.5-3 in establishing prior authorization requirements for mental health drugs. The Contractor may require prior authorization requirements, such as general member information, a justification of need for drug related to the medical needs of the member and a planned course of treatment, if applicable, as related to the number drug provided and duration of treatment. The Contractor will be required to have a process in place to allow drugs that are medically necessary but not included on the formulary to be accessed by members. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. These criteria and edits must be reviewed and approved by the DUR Board prior to implementation. Additionally, the Contractor shall implement a retrospective drug utilization program to analyze for drugs or specific groups of drugs to document utilization trends and intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost effective care. The Contractor must also implement a program to identify and report fraud and abuse among providers and members.
Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations. For any drugs which require prior authorization, the Contractor shall provide a response by telephone or other telecommunication device within twenty-four (24) hours of a request for prior authorization. Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour supply of a covered outpatient prescription drug in an emergency situation as required under 42 U.S.C 1396r- 8(d)(5)(B). The Contractor shall comply with the requirements of IC 12-15- 35.5-3 in establishing prior authorization requirements for mental health drugs. The Contractor may require prior authorization requirements, such as general member information, a justification of need for drug related to the medical needs of the member and a planned course of treatment, if applicable, as related to the number drug provided and duration of treatment. The Contractor will be required to have a process in place to allow drugs that are medically necessary but not included on the formulary to be accessed by members. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. These criteria and edits must be reviewed and approved by the DUR Board prior to implementation.
