Pharmacy Program Management Clause Samples

Pharmacy Program Management. The Contractor shall assure that pharmacy benefits are administered in accordance with the state and Federal laws and regulations. In the event the prescription is for a non-preferred drug and the pharmacist cannot reach the physician or the Contractor or its agent for approval and the pharmacist deems it necessary, a seventy-two (72) hour emergency supply shall be provided. If the physician prescribed an amount of the medicine that is less than a seventy-two (72) hour supply, the pharmacist shall only dispense the amount prescribed. Except for those Members diagnosed with conditions listed in 907 KAR 1:019, Kentucky Medicaid members may be limited to three (3) brand prescriptions and four (4) total prescriptions, based upon their diagnoses and/or medical condition. If the Contractor charges co-payments for prescription medications dispensed to Members such charges shall be at the same level as the Department in the Fee for Service Program. The Contractor shall track and reports on the Members’ usage and co-payments, including accumulation of maximum out-of-pocket co-payments. The co-payments requirements for the Kentucky Medicaid Program can be found in 907 KAR 1:604. Whether the Contractor imposes such co-pays or not, the actuarial value of the co-pays will be reflected in the Capitation Rate adjustments anticipated to take place with the ACA implementation as provided in Section 11.2.