ENROLLEE RESTRICTION Sample Clauses
ENROLLEE RESTRICTION. Contractor must have an Enrollee restriction program in place, in which, at a minimum, Contractor must restrict an Enrollee for a reasonable period to a designated PCP or Provider of pharmacy services when:
ENROLLEE RESTRICTION. 4.19.1 Contractor must have an Enrollee restriction program in place, in which, at a minimum, Contractor must restrict an Enrollee for a reasonable period to a designated PCP or Provider of pharmacy services when:
4.19.1.1 the Department indicates the Enrollee was included in the Department’s Recipient Restriction Program pursuant to 89 Ill. Admin. Code 120.80 prior to enrollment with Contractor; or
4.19.1.2 Contractor determines that the Enrollee is over-utilizing Covered
ENROLLEE RESTRICTION. 4.19.1 Contractor must have an Enrollee restriction program in place, in which, at a minimum, Contractor must restrict an Enrollee for a reasonable period to a designated PCP or Provider of pharmacy services when:
4.19.1.1 the Department indicates the Enrollee was included in the Department’s Recipient Restriction Program pursuant to 89 Ill. Admin. Code 120.80 prior to enrollment with Contractor; or
4.19.1.2 Contractor determines that the Enrollee is over-utilizing Covered Services. Contractor's criteria for such determination, and the conditions of the restriction, must meet the standards of 42 CFR §431.54(e).