Common use of Pharmacy Access Clause in Contracts

Pharmacy Access. For purposes of this section, "prescription" shall include authorization for legend and over the counter drugs covered by Medicaid policy. a. Pharmacies must be available and accessible on a statewide basis. The MCO shall: 1. Maintain a comprehensive provider network of pharmacies that will within available resources assure twenty four (24) hour access to pharmaceutical goods and services; 2. Have established protocols to respond to urgent requests for medications; 3. Monitor and take steps to correct excessive utilization of regulated substances; and 4. Require pharmacists to utilize the Automated Eligibility Verification System (AEVS) to determine client eligibility and MCO affiliation when there is a discrepancy between the information in the MCO's eligibility system and information given to the pharmacists by the Member, the Member's physician or other third party. b. The MCO shall require that its provider network of pharmacies offer medically necessary goods and services to the MCO's Members. The MCO may have a drug management program that includes a prescription drug formulary. The MCO drug formulary must include only Food and Drug Administration approved drug products and must be broad enough in scope to meet the needs of all Members. The MCO drug formulary shall consist of a reasonable selection of drugs which do not require prior approval for each specific therapeutic drug class. c. The MCO shall submit a copy of its formulary to the DEPARTMENT no later than thirty (30) days after the effective date of this contract. The MCO shall submit any subsequent deletions to the formulary to the DEPARTMENT thirty (30) days prior to making the change. The MCO shall also submit subsequent additions to the formulary immediately without seeking prior approval by the DEPARTMENT. The DEPARTMENT reserves the right to identify deficiencies in the content or operation of the formulary. In this instance, the MCO shall have thirty (30) days to address in writing the identified deficiencies to the DEPARTMENT's satisfaction. The MCO may request to meet with the DEPARTMENT prior to submission of the written response. d. The MCO shall ensure that Members using maintenance drugs (drugs usually prescribed to treat long-term or chronic conditions including, but not limited to, diabetes, arthritis and high blood pressure) are informed in advance, but no less than thirty (30) days in advance of any changes to the prescription drug formulary related to such maintenance drugs if the Member using the drug will not be able to continue using the drug without a new authorization. If a Member requests a grievance and administrative hearing concerning a denial or termination that results from or relates to the removal of the maintenance drug from the formulary, the MCO shall continue to authorize the drug for that Member pending a hearing decision. e. The MCO shall require that its provider network of pharmacies adheres to the provisions of Connecticut General Statutes Section 20-619 (b) and (c) related to generic substitutions for Medicaid recipients. f. If the MCO maintains a drug formulary, the MCO shall have a prior authorization process to permit access, at a minimum, to all medically necessary and appropriate drugs covered for the Medicaid fee-for-service population. Medicaid pharmacy policy is set forth at Sections 174 through 174H.IV.A.4 of the Regulations of Connecticut State Agencies. The MCO shall develop a timely and efficient authorization process to obtain information from providers on medical necessity for a non-formulary drug, a formulary drug requiring prior authorization or a brand name drug where a generic substitution is available. The MCO shall make an individualized determination concerning medical necessity in each instance when a Member's prescribing provider requests a non-formulary drug, formulary drug requiring prior authorization or a brand name drug in accordance with the provisions of (e) above. If no request for prior authorization has been received by the MCO or the Pharmacy Benefits Manager (PBM) prior to the submission of a prescription to a pharmacy, the pharmacist may contact the prescribing physician and inform him or her of the prior authorization requirement. g. Except as provided in subsection (j) below, in the event that a provider requests authorization for, or prescribes a non-formulary drug, a formulary drug requiring prior authorization or a brand name drug where a generic substitution is available prior to prescribing a prescription for that drug, but elects during the prior authorization process or in discussions with the pharmacist to prescribe a formulary, generic or alternate formulary drug that the provider agrees will be equally effective for the Member, the MCO is not required to issue a notice of action and is not required to provide a temporary supply of the drug for which the provider initially sought authorization. h. In the event that a provider requests authorization, or prescribes a non-formulary drug, a formulary drug requiring prior authorization or a brand name drug where a generic substitution is available, and the provider and the MCO cannot reach an agreement that another drug is equally effective, the MCO shall issue a notice of action. The MCO or its PBM shall without delay authorize a thirty (30) day temporary supply of the drug if the provider certifies to the MCO or its PBM that the drug is necessary to address an urgent or emergent condition. The MCO is also required to authorize a thirty (30) day temporary supply of the drug on the day of submission of the prescription to the pharmacy if the MCO has been unable to contact the provider to discuss an effective formulary drug during normal business hours. The certification shall be in a manner to be specified by the MCO, subject to the DEPARTMENT's approval. If the original prescription was for a period less then thirty (30) days, the override will be for the period prescribed. If the Member, upon receipt of the notice of action, requests a grievance and administrative hearing within ten (10) days, the MCO shall continue to authorize the drug for the Member pending a hearing decision or other resolution of the dispute concerning the prescription. If the Member does not request a grievance and administrative hearing, the MCO is not required to authorize any further refills. i. The MCO shall, on a quarterly basis, in a format specified and approved by the DEPARTMENT, submit a report detailing its prior authorization process to the DEPARTMENT or its agent to be developed jointly between the DEPARTMENT and the MCOs. j. If the DEPARTMENT or its agent determines that there is a pattern of denials for requested authorization for particular drugs, or any other pattern suggesting that the MCO's authorization process is one that does not appropriately consider each Member's individualized medical needs, the DEPARTMENT may require notices of action in circumstances other than those described above and/or may require the addition of a particular drug or drugs to the MCO's formulary as drugs that do not require prior authorizations.

Pharmacy Access. For purposes of this section, "prescription" shall include authorization for legend and over the over-the-counter drugs covered by Medicaid policy. a. The MCO shall be responsible for payment for pharmacy services regardless of a Member's diagnosis. The only exception is that the CT BHP shall be responsible for methadone costs that are part of the bundled reimbursement for methadone maintenance and ambulatory detox providers. Prescribing behavioral health providers participating in the CT BHP will follow the applicable pharmacy program requirements, including the formulary, of the MCO. These providers will provide the MCO with any clinical information needed to support requests for authorization or the preparation of summaries for administrative hearings. The MCO shall promptly inform the DEPARTMENT of any changes to its pharmacy program requirements. b. Pharmacies must be available and accessible on a statewide basis. The MCO shall: 1. Maintain a comprehensive provider network of pharmacies that will will, within available resources resources, assure twenty four (24) hour access to pharmaceutical goods and services; 2. The MCO may establish a pharmacy lock-in program for Members suspected of abuse or excessive utilization. Any MCO pharmacy lock-in program will be subject to DEPARTMENT approval; 3. Have established protocols to respond to urgent requests for medications; 34. Monitor and take steps to correct excessive utilization of regulated substances, including but not limited to, restricting pharmacy access pursuant to a pharmacy lock-in program approved by the DEPARTMENT; and 45. Require pharmacists to utilize the Automated Eligibility Verification System (AEVS) to determine client eligibility and MCO affiliation when there is a discrepancy between the information in the MCO's eligibility system and information given to the pharmacists by the Member, the Member's physician or other third party. b. c. The MCO shall require that its provider network of pharmacies offer medically necessary goods and services to the MCO's Members. . d. The MCO may have a drug management program that includes a prescription drug formulary. 1. The MCO drug formulary must include only Food and Drug Administration approved drug products and must be broad enough in scope to meet the needs of all Members. 2. The For each specific therapeutic drug class the MCO drug formulary shall consist of a reasonable selection of drugs which that do not require prior approval for each specific therapeutic drug classapproval. c. e. The MCO shall submit a copy of obtain the DEPARTMENT'S written approval prior to deleting any drugs from its formulary or issuing any communication regarding its proposed formulary changes. In addition the MCO shall: 1. Submit any deletions to its formulary and any new prior authorization requirements for formulary drugs to the DEPARTMENT no later than at least thirty (30) days after the effective date of this contractprior to making any such change. 2. The MCO shall submit any subsequent deletions Submit all physician, pharmacist and Member letters, notices, e- mail alerts or other electronic or written communications related to the proposed formulary change to the DEPARTMENT thirty (30) days prior to making issuing or sending any such communication. 3. If, however, the changeDEPARTMENT does not respond to proposed formulary changes or communications submitted for approval within thirty (30) days of receipt from the MCO, the MCO may proceed with the change or issue the communication, as applicable. 4. The MCO shall also submit Submit subsequent additions to the formulary immediately at the time the addition is made without seeking prior approval by the DEPARTMENT and regardless of whether the drug(s) to be added requires prior authorization. If the MCO's formulary includes a legend drug that requires prior authorization and the FDA approves the drug for over-the-counter use, the MCO is not required to seek the DEPARTMENT'S approval to substitute the over-the-counter version with a prior authorization requirement. 5. Notify prescribing providers thirty (30) days in advance of any changes to the MCO's formulary. The DEPARTMENT reserves the right to identify clinical deficiencies in the content of or operation operational deficiencies of the MCO's formulary. In this instance, the MCO shall have thirty (30) days to address in writing the identified deficiencies to the DEPARTMENT's 'S satisfaction. The MCO may request to meet with the DEPARTMENT prior to submission of the written response. If the DEPARTMENT is not satisfied with the MCO's response, the DEPARTMENT may require the MCO to add specific drugs to its formulary or to or eliminate prior authorization requirements for specific drugs. If the MCO disputes the DEPARTMENT'S determination, the MCO may exercise its rights pursuant to section 7.02 of this Contract. d. f. The MCO shall ensure that Members using maintenance drugs (drugs usually prescribed to treat long-long term or chronic conditions including, but not limited to, to diabetes, arthritis and high blood pressure) are informed in advance, but no less than thirty (30) days in advance of any changes to the prescription drug formulary related to such maintenance drugs if the Member using the drug will not be able to continue using the drug without a new authorization. 1. When the MCO deletes a drug from its formulary or imposes prior authorization requirements on additional drug(s), the MCO shall identify to the DEPARTMENT which of the affected drugs the MCO intends to treat as maintenance drugs. 2. The DEPARTMENT may require the MCO to treat additional drugs as maintenance drugs for purposes of this subsection and subsection (e). 3. If the MCO treats all drugs affected by a formulary change as maintenance drugs for purposes of this subsection and for purposes of subsection (g) below, the MCO is not required to designate specific drugs as maintenance drugs. In such circumstances, the MCO shall notify the DEPARTMENT that all drugs affected by the formulary change will be treated in the same manner. g. If a prescribing provider seeks authorization to continue a maintenance drug that is being removed from the MCO's formulary or subjected to new prior authorization requirements at any time prior to the effective date of the change, the MCO shall conduct a medical necessity review. 1. The MCO shall conduct the review, and, if the MCO does not approve the request, the MCO shall issue a notice of action in accordance with the provisions of subsection (i) below. 2. If the MCO denies the prior authorization request for the maintenance drug, the MCO shall issue a notice of action at least ten days in advance of the effective date of the action. 3. The MCO shall automatically continue authorization for the maintenance drug for at least the medical necessity review period plus, if the MCO does not approve the authorization, for the ten (10) day advance notice period, or the effective date of the action, whichever is later. 4. If a Member requests a grievance an appeal and administrative hearing concerning a denial or termination that results from or relates to the imposition of new prior authorization requirements for or removal of the maintenance drug from the formulary, the MCO shall continue to authorize the drug for that Member pending a hearing decision. e. 5. If the prescriber does not initiate the prior authorization process prior to the expiration of the existing authorization period, the Member shall receive a temporary supply of the maintenance drug if the conditions described in subsection (i) are met. 6. If the MCO grandfathers some or all Members affected by the formulary changes for a period of more than ninety (90) days, the MCO shall either: a) Send a second advance notice letter at least thirty (30) days prior to the end of the extended authorization period or b) Ensure that if the Member's prescriber requests authorization prior to the end of the existing authorization period, that if the request is denied and the Member appeals, that the authorization will continue pending appeal. h. The MCO shall require that its provider network of pharmacies adheres adhere to the provisions of Connecticut General Statutes Section § 20-619 (b) and (c) related to generic substitutions for Medicaid recipients. f. i. If the MCO maintains a drug formulary, the MCO shall have a prior authorization process to permit access, at a minimum, to all medically necessary and appropriate drugs covered for the Medicaid fee-for-service population. Medicaid pharmacy policy is set forth at Sections 174 through 174H.IV.A.4 of the Regulations of Connecticut State Agencies. 1. The MCO shall develop a timely and efficient authorization process to obtain information from providers on medical necessity for a non-Part II 30 formulary drug, a formulary drug requiring prior authorization or a brand name drug where a generic substitution is available. 2. The MCO shall make an individualized determination concerning medical necessity and appropriateness in each instance when a Member's prescribing provider requests a non-formulary drug, formulary drug requiring prior authorization or a brand name drug including request made in accordance with relation to the provisions of (ef) above. 3. If no request for prior authorization has been received by the MCO or the Pharmacy Benefits Manager (PBM) does not receive a request for prior authorization prior to the submission of a prescription to a pharmacy, the pharmacist may contact the prescribing physician and inform him or her of the prior authorization requirement. g. j. Except as provided in subsection (jp) below, in the event that a provider requests authorization for, or prescribes a non-formulary drug, a formulary drug requiring prior authorization or a brand name drug where a generic substitution is available prior to prescribing a prescription for that drug, but elects during the prior authorization process or in discussions with the pharmacist to prescribe a formulary, generic or alternate formulary drug that the provider agrees will be equally effective for the Member, the MCO is not required to issue a notice of action and is not required to provide a temporary supply of the drug for which the provider initially sought authorization. h. k. In the event that a provider requests authorization, or prescribes a non-formulary drug, a formulary drug requiring prior authorization or a brand name drug where a generic substitution is availableavailable the MCO must approve or deny the request as expeditiously as the Member's health condition requires, but no later than 14 calendar days following the MCO's receipt of the request. An additional 14 calendar days will be allowed if: 1) the Member or the requesting provider asks for the extension or 2) the MCO or its PBM documents that the extension is in the Member's interest because additional information is needed for the MCO to authorize the service and the failure to extend the authorization timeframe will result in denial of the service. The DEPARTMENT may request and review such documentation from the MCO. l. In the event that a provider and certifies to the MCO cannot reach an agreement or its PBM that another the drug is equally effectivenecessary to address an urgent or emergent condition or that the standard authorization period could seriously jeopardize the Member's life or health or ability to attain, maintain or regain maximum function, the MCO shall issue a or its PBM must make an expedited authorization decision and provide notice as expeditiously as the member's health condition requires and no later than 3 working days after receipt of actionthe request for service. The MCO or its PBM may extend the 3 working days time period by up to 14 additional calendar days if: 1) the Member or the provider requests the extension, or 2) if the MCO or its PBM documents that the extension is in the Member's interest because additional information is needed for the MCO to authorize the service and the failure to extend the authorization timeframe will result in denial of the service. The DEPARTMENT may request such documentation from the MCO. m. The MCO or its PBM shall without delay authorize up to a thirty (30) day temporary supply of the drug if the provider certifies to the MCO or its PBM that the drug is necessary to address an urgent or emergent condition. The MCO is also required to authorize a thirty (30) day temporary supply of the drug on the day of submission of the prescription to the pharmacy if the MCO has been unable to contact the provider to discuss an effective formulary drug during normal business hours. The certification shall be in a manner to be specified by the MCO, subject to the DEPARTMENT's 'S approval. If the original prescription was for a period less then thirty (30) days, the override temporary supply will be for the period prescribed. . n. If the Member, upon receipt of the a termination, suspension or reduction notice of action, timely requests a grievance an appeal and administrative hearing within ten (10) days, the MCO shall continue to authorize the drug for the Member pending a hearing decision or other resolution of the dispute concerning the prescription. As used within this section, "timely" means filing on or before the later of the following: (1) within ten (10) days of the MCO mailing of the notice of action; or (2) the intended effective date of the MCO's proposed action. If the Member does not request a grievance an appeal and administrative hearing, the MCO is not required to authorize any further refills. i. o. Notwithstanding anything to the contrary in the preceding, the MCO shall not cover drugs used to treat sexual or erectile dysfunction, as set forth in 1927(d)(2)(K) of section 1903(i) of the Social Security Act as amended, unless such drugs are used to treat conditions other than sexual or erectile dysfunction and the uses have been approved by the Food and Drug Administration. p. The MCO shall, on a quarterly basis, in a format specified and approved by submit the DEPARTMENT, submit a report detailing its prior authorization process to the DEPARTMENT or its agent to be developed jointly between the DEPARTMENT and the MCOs.at Appendix L. j. q. If the DEPARTMENT or its agent determines that there is a pattern of denials for requested authorization for particular drugs, or any other pattern suggesting that the MCO's authorization process is one that does not appropriately consider each Member's individualized medical needs, the DEPARTMENT may require notices of action in circumstances other than those described above and/or may require the addition of a particular drug or drugs to the MCO's formulary as drugs that do not require prior authorizations.