Common use of Dispensing and Monitoring Requirements Clause in Contracts

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. 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-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. 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-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. To conform to 42 CFR 437-438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization criteria for access to a prescription drug is developed, the Contractor’s criteria must be consistent with the amount, duration and scope of that criteria and may not be more stringent. 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.EXHIBIT 1.E

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) 72- hour emergency supply of a restricted drug. The automated system shall allow the pharmacist to dispense the seventy72-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. To conform to 42 CFR 437-438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization criteria for access to a prescription drug is developed, the Contractor’s criteria EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK must be consistent with the amount, duration and scope of that criteria and may not be more stringent. 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.. Administration of all criteria, common or independent, shall be performed by the Contractor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers;

Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations, and State pharmacy policy. The Contractor shall comply with For the requirements of IC 12-15-35.5-3 in establishing prescribing limits to mental health drugsSUPDL drug classes that indicate them, the Contractor’s quantity limits, and age edits must follow the SUPDL unless otherwise reviewed and prior approved by the State. 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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two seventy -two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. The Contractor shall employ an automated system allow for approval of a seventy90-two day supply for maintenance drugs (72) hour emergency supply of a restricted drugdoes not apply to specialty drugs). 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 for the SUPDL approved for all plans, 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 processFor non-formulary covered drug classes, the Contractor may require apply 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 quantity of 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 in the formulary or non- formulary covered drug lists to be accessed by members. The Contractor will be required to accept prior authorization requests via telephone, fax, web-based system, or in writing. To conform to 42 CFR 438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), any medical necessity criteria applied by the Contractor may not be more stringent than any established FFS criteria for non- formulary covered drug classes. For formulary (SUPDL) drug classes, the Contractor shall follow the SUPDL criteria. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in linked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a common format, alongside fee retrospective drug utilization program to analyze for service drugs or specific groups of drugs to document utilization trends and other intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost-effective care. The Contractor criteriamust also implement a program to identify and report fraud and abuse among providers and members. 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. 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 seventy72-two (72) hour emergency supply of a restricted drug. The automated system shall allow the pharmacist to dispense the seventy72-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.. Administration of all criteria, common or independent, shall be performed by the Contractor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers;

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 12-15-15- 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 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 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. To conform to 42 CFR 437-438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization criteria for access to a prescription drug is developed, the EXHIBIT 1.E SCOPE OF WORK – HOOSIER HEALTHWISE Contractor’s criteria must be consistent with the amount, duration and scope of that criteria and may not be more stringent. 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. 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 Emergency EXHIBIT 1 SCOPE OF WORK supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. 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 quantity of drug provided and duration of treatment. The Contractor will be required to have a process in place to allow drugs that are member access to medically necessary but not included on non-preferred (non-formulary) drugs. To conform to 42 CFR 437-438.3(s) and the formulary to be accessed by members. The Contractor will be required to accept Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization requests via telephonecriteria for access to a prescription drug is developed, faxthe Contractor’s criteria must be consistent with the amount, web-based system, or in writingduration and scope of that criteria and may not be more stringent. 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 These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in a common format, alongside fee for service and other Contractor criterialinked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a retrospective drug use review 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 patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, and report fraud and abuse among physicians, pharmacists providers and individuals receiving benefits, or associated with specific drugs or groups of drugsmembers.

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 12-15-15- 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 seventy72-two (72) hour emergency supply of a restricted drug. The automated system shall allow the pharmacist to dispense the seventy72-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.. Administration of all criteria, common or independent, shall be performed by the Contractor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers;

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 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 seventy72-two (72) hour emergency supply of a restricted drug. The automated system shall allow the pharmacist to dispense the seventy72-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 devel opment 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. To conform to 42 CFR 437- 438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization criteria for access to a prescription drug is developed, the Contractor’s criteria must be consistent with the amount, duration and scope of that criteria and may not be more stringent. 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.. EXHIBIT 2.I SCOPE OF WORK – HEALHTY INDIANA PLAN Administration of all criteria, common or independent, shall be performed by the Contrac tor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers;

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 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 seventy72-two (72) hour emergency supply of a restricted drug. The automated system shall allow the pharmacist to dispense the seventy72-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. To conform to 42 CFR 437- 438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization criteria for access to a prescription drug is developed, the Contractor’s criteria must be consistent with the amount, duration and scope of that criteria and may not be more stringent. 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.. EXHIBIT 2.I SCOPE OF WORK – HEALTHY INDIANA PLAN Administration of all criteria, common or independent, shall be performed by the Contractor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers;

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 EXHIBIT 1 SCOPE OF WORK 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 Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. 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 quantity of drug provided and duration of treatment. The Contractor will be required to have a process in place to allow drugs that are member access to medically necessary but not included on non-preferred (non-formulary) drugs. To conform to 42 CFR 437-438.3(s) and the formulary to be accessed by members. The Contractor will be required to accept Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization requests via telephonecriteria for access to a prescription drug is developed, faxthe Contractor’s criteria must be consistent with the amount, web-based system, or in writingduration and scope of that criteria and may not be more stringent. 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 These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in a common format, alongside fee for service and other Contractor criterialinked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a retrospective drug use review 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 patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, and report fraud and abuse among physicians, pharmacists providers and individuals receiving benefits, or associated with specific drugs or groups of drugsmembers.

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.. Administration of all criteria, common or independent, shall be performed by the Contractor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers;

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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. 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 requirementsrequirements in compliance with 42 CFR 438.3(s)(6) and section 1927(d)(5) of the Social Security Act, 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 quantity of drug provided and duration of treatment. The Contractor will be required to have a process in place to allow drugs that are member access to medically necessary but not included on non-preferred (non-formulary) drugs. To conform to 42 CFR 437-438.3(s) and the formulary to be accessed by members. The Contractor will be required to accept Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization requests via telephonecriteria for access to a prescription drug is developed, faxthe Contractor’s criteria must be EXHIBIT 1 SCOPE OF WORK – HEALTHY INDIANA PLAN consistent with the amount, web-based system, or in writingduration and scope of that criteria and may not be more stringent. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in linked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a common format, alongside fee retrospective drug utilization program to analyze for service drugs or specific groups of drugs to document utilization trends and other intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost -effective care. The Contractor criteriamust also implement a program to identify and report fraud and abuse among providers and members. 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, and State pharmacy policy. The Contractor shall comply with For the requirements of IC 12-15-35.5-3 in establishing prescribing SUPDL drug classes that indicate them, the Contractor’s quantity limits to mental health drugsand age edits must follow the SUPDL unless otherwise reviewed and prior approved by the State. For any drugs which require prior authorization, the Contractor shall provide a response by telephone or other telecommunication device devic e within twenty-four (24) hours of a request for prior authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two seventy -two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. The Contractor shall employ an automated system allow for approval of a seventy90-two day supply for maintenance drugs (72) hour emergency supply of a restricted drugdoes not apply to specialty drugs). 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 for the SUPDL approved for all plans, 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 processFor non-formulary covered drug classes, the Contractor may require apply 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 quantity of 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 in the formulary or non- formulary covered drug lists to be accessed by members. The Contractor will be required to accept prior authorization requests via telephone, fax, web-based system, or in writing. To conform to 42 CFR 438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), any medical necessity criteria applied by the Contractor may not be more stringent than any established FFS criteria for non- formulary covered drug classes. For formulary (SUPDL) drug classes, the Contractor shall follow the SUPDL criteria. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in a common format, alongside fee for service and other Contractor criterialinked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a retrospective drug use review utilization program 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 analyze for drugs or specific groups of drugs.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

Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations, and State pharmacy policy. The Contractor shall comply with For the requirements of IC 12-15-35.5-3 in establishing prescribing SUPDL drug classes that indicate them, the Contractor’s quantity limits to mental health drugsand age edits must follow the SUPDL unless otherwise reviewed and prior approved by the State. 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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two seventy -two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. The Contractor shall employ an automated system allow for approval of a seventy90-two day supply for maintenance drugs (72) hour emergency supply of a restricted drugdoes not apply to specialty drugs). 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 for the SUPDL approved for all plans, 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 processFor non-formulary covered drug classes, the Contractor may require apply 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 quantity of 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 in the formulary or non- formulary covered drug lists to be accessed by members. The Contractor will be required to accept prior authorization requests via telephone, fax, web-based system, or in writing. To conform to 42 CFR 438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), any medical necessity criteria applied by the Contractor may not be more stringent than any established FFS criteria for non- formulary covered drug classes. For formulary (SUPDL) drug classes, the Contractor shall follow the SUPDL criteria. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in a common format, alongside fee for service and other Contractor criterialinked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a retrospective drug use review utilization program 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 analyze for drugs or specific groups of drugs.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

Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations, and State pharmacy policy. The Contractor shall comply with For the requirements of IC 12-15-35.5-3 in establishing prescribing SUPDL drug classes that indicate them, the Contractor’s quantity limits to mental health drugsand age edits must follow the SUPDL unless otherwise reviewed and prior approved by the State. 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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. The Contractor shall employ an automated system allow for approval of a seventy90-two day supply for maintenance drugs (72) hour emergency supply of a restricted drugdoes not apply to specialty drugs). 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 for the SUPDL approved for all plans, 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 processFor non-formulary covered drug classes, the Contractor may require apply 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 quantity of 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 in the formulary or non- formulary covered drug lists to be accessed by members. The Contractor will be required to accept prior authorization requests via telephone, fax, web-based system, or in writing. To conform to 42 CFR 438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), any medical necessity criteria applied by the Contractor may not be more stringent than any established FFS criteria for non- formulary covered drug classes. For formulary (SUPDL) drug classes, the Contractor shall follow the SUPDL criteria. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in a common format, alongside fee for service and other Contractor criterialinked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a retrospective drug use review utilization program 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 analyze for drugs or specific groups of drugs.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

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 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 seventy72-two (72) hour emergency supply of a restricted drug. The automated system shall allow the pharmacist to dispense the seventy72-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 devel opment 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. To conform to 42 CFR 437- 438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization criteria for access to a prescription drug is developed, the Contractor’s criteria must be consistent with the amount, duration and scope of that criteria and may not be more stringent. 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.. EXHIBIT 2.I SCOPE OF WORK – HEALTHY INDIANA PLAN Administration of all criteria, common or independent, shall be performed by the Contrac tor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers;

Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations, and State pharmacy policy. The Contractor shall comply with For the requirements of IC 12-15-35.5-3 in establishing prescribing limits to mental health drugsSUPDL drug classes that indicate them, the Contractor’s quantity limits, and age edits must follow the SUPDL unless otherwise reviewed and prior approved by the State. 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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. The Contractor shall employ an automated system allow for approval of a seventy90-two day supply for maintenance drugs (72) hour emergency supply of a restricted drugdoes not apply to specialty drugs). 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 for the SUPDL approved for all plans, 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 processFor non-formulary covered drug classes, the Contractor may require apply 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 quantity of 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 in the formulary or non- formulary covered drug lists to be accessed by members. The Contractor will be required to accept prior authorization requests via telephone, fax, web-based system, or in writing. To conform to 42 CFR 438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), any medical necessity criteria applied by the Contractor may not be more stringent than any established FFS criteria for non- formulary covered drug classes. For formulary (SUPDL) drug classes, the Contractor shall follow the SUPDL criteria. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in linked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a common format, alongside fee retrospective drug utilization program to analyze for service drugs or specific groups of drugs to document utilization trends and other intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost-effective care. The Contractor criteriamust also implement a program to identify and report fraud and abuse among providers and members. 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. The Contractor shall comply with the requirements of IC 12-15-15- 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 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. To conform to 42 CFR 437-438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization criteria for access to a prescription drug is developed, the EXHIBIT 1.E SCOPE OF WORK – HOOSIER HEALTHWISE Contractor’s criteria must be consistent with the amount, duration and scope of that criteria and may not be more stringent. 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. 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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. 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 requirementsrequirements in compliance with 42 CFR 438.3(s)(6) and section 1927(d)(5) of the Social Security Act, 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 quantity of drug provided and duration of treatment. The Contractor will be required to have a process in place to allow drugs that are member access to medically necessary but not included on non-preferred (non-formulary) drugs. To conform to 42 CFR 437-438.3(s) and the formulary to be accessed by members. The Contractor will be required to accept Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization requests via telephonecriteria for access to a prescription drug is developed, faxthe Contractor’s criteria must be consistent with the amount, web-based system, or in writingduration and scope of that criteria and may not be more stringent. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in linked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a common format, alongside fee retrospective drug utilization program to analyze for service drugs or specific groups of drugs to document utilization trends and other intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost -effective care. The Contractor criteriamust also implement a program to identify and report fraud and abuse among providers and members. EXHIBIT 1 SCOPE OF WORK – HEALTHY INDIANA PLAN 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. 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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. 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 requirementsrequirements in compliance with 42 CFR 438.3(s)(6) and section 1927(d)(5) of the Social Security Act, such as general member EXHIBIT 1 SCOPE OF WORK – HEALTHY INDIANA PLAN 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 quantity of drug provided and duration of treatment. The Contractor will be required to have a process in place to allow drugs that are member access to medically necessary but not included on non-preferred (non-formulary) drugs. To conform to 42 CFR 437-438.3(s) and the formulary to be accessed by members. The Contractor will be required to accept Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization requests via telephonecriteria for access to a prescription drug is developed, faxthe Contractor’s criteria must be consistent with the amount, web-based system, or in writingduration and scope of that criteria and may not be more stringent. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in linked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a common format, alongside fee retrospective drug utilization program to analyze for service drugs or specific groups of drugs to document utilization trends and other intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost -effective care. The Contractor criteriamust also implement a program to identify and report fraud and abuse among providers and members. 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. 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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. EXHIBIT 1 SCOPE OF WORK – HEALTHY INDIANA PLAN 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 requirementsrequirements in compliance with 42 CFR 438.3(s)(6) and section 1927(d)(5) of the Social Security Act, 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 quantity of drug provided and duration of treatment. The Contractor will be required to have a process in place to allow drugs that are member access to medically necessary but not included on non-preferred (non-formulary) drugs. To conform to 42 CFR 437-438.3(s) and the formulary to be accessed by members. The Contractor will be required to accept Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization requests via telephonecriteria for access to a prescription drug is developed, faxthe Contractor’s criteria must be consistent with the amount, web-based system, or in writingduration and scope of that criteria and may not be more stringent. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in linked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a common format, alongside fee retrospective drug utilization program to analyze for service drugs or specific groups of drugs to document utilization trends and other intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost -effective care. The Contractor criteriamust also implement a program to identify and report fraud and abuse among providers and members. 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, and State pharmacy policy. The Contractor shall comply with For the requirements of IC 12-15-35.5-3 in establishing prescribing SUPDL drug classes that indicate them, the Contractor’s quantity limits to mental health drugsand age edits must follow the SUPDL unless otherwise reviewed and prior approved by the State. 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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two seventy -two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. The Contractor shall employ an automated system allow for approval of a seventy90-two day supply for maintenance drugs (72) hour emergency supply of a restricted drugdoes not apply to specialty drugs). 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 for the SUPDL approved for all plans, 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 processFor non-formulary covered drug classes, the Contractor may require apply 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 quantity of 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 in the formulary or non- formulary covered drug lists to be accessed by members. The Contractor will be required to accept prior authorization requests via telephone, fax, web-based system, or in writing. To conform to 42 CFR 438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), any medical necessity criteria applied by the Contractor may not be more stringent than any established FFS criteria for non- formulary covered drug classes. For formulary (SUPDL) drug classes, the Contractor shall follow the SUPDL criteria. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in linked to the xxxxx://xxx.xx.xxx/medi caid/ website. Additionally, the Contractor shall implement a common format, alongside fee retrospective drug utilization program to analyze for service drugs or specific groups of drugs to document utilization trends and other intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost-effective care. The Contractor criteriamust also implement a program to identify and report fraud and abuse among providers and members. 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.. ▪ (1) Administration of all criteria, common or independent, shall be performed by the Contractor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers

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 seventy72-two (72) hour emergency supply of a restricted drug. The automated system shall allow the pharmacist to dispense the seventy72-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.. Administration of all criteria, common or independent, shall be performed by the Contractor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers;

Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations, and State pharmacy policy. The Contractor shall comply with For the requirements of IC 12-15-35.5-3 in establishing prescribing SUPDL drug classes that indicate them, the Contractor’s quantity limits to mental health drugsand age edits must follow the SUPDL unless otherwise reviewed and prior approved by the State. 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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two seventy -two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. The Contractor shall employ an automated system allow for approval of a seventy90-two day supply for maintenance drugs (72) hour emergency supply of a restricted drugdoes not apply to specialty drugs). 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 for the SUPDL approved for all plans, 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 processFor non-formulary covered drug classes, the Contractor may require apply 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 quantity of 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 in the formulary or non- formulary covered drug lists to be accessed by members. The Contractor will be required to accept prior authorization requests via telephone, fax, web-based system, or in writing. To conform to 42 CFR 438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), any medical necessity criteria applied by the Contractor may not be more stringent than any established FFS criteria for non- formulary covered drug classes. For formulary (SUPDL) drug classes, the Contractor shall follow the SUPDL criteria. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in linked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a common format, alongside fee retrospective drug utilization program to analyze for service drugs or specific groups of drugs to document utilization trends and other intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost-effective care. The Contractor criteriamust also implement a program to identify and report fraud and abuse among providers and members. 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.. ▪ (1) Administration of all criteria, common or independent, shall be performed by the Contractor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers

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 authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour Emergency supply of a covered outpatient prescription drug in an emergency situation drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. 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 requirementsrequirements in compliance with 42 CFR 438.3(s)(6) and section 1927(d)(5) of the Social Security Act, 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 quantity of drug provided and duration of treatment. The Contractor will be required to have a process in place to allow drugs that are member access to medically necessary but not included on non- preferred (non-formulary) drugs. To conform to 42 CFR 437-438.3(s) and the formulary to be accessed by members. The Contractor will be required to accept Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization requests via telephonecriteria for access to a prescription drug is developed, faxthe Contractor’s criteria must be consistent with the amount, web-based system, or in writingduration and scope of that criteria and may not be more stringent. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. Independently developed These criteria and implemented PA edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be displayedposted online, in linked to the xxxxx://xxx.xx.xxx/medicaid/ website. Additionally, the Contractor shall implement a common format, alongside fee retrospective drug utilization program to analyze for service drugs or specific groups of drugs to document utilization trends and other intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost-effective care. The Contractor criteriamust also implement a program to identify and report fraud and abuse among providers and members. 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.