Pharmacy Requirements Clause Samples

Pharmacy Requirements. 5.3.1 Pharmacy Formulary Effective January 1, 2018 through June 30, 2018. 5.3.1.1 Contractor shall submit its Pharmacy Formulary for Prior Approval initially and annually thereafter. 5.3.1.2 Contractor shall provide coverage of drugs in all classes of drugs for which the Department’s FFS program provides coverage.‌ 5.3.1.3 Contractor shall cover only drugs made by manufacturer who participate in the federal Medicaid drug rebate program, which applies to both prescription and over-the-counter drugs, but does not apply to non-drug items such as blood-glucose test strips. The department will provide a listing of manufacturers that participate in the federal Medicaid drug rebate program. 5.3.1.4 Contractor may determine its own utilization controls, including, but not limited to, step therapy and prior approval, unless otherwise prohibited under this Contract, to ensure appropriate utilization. Contractor shall utilize the Department’s step therapy and prior authorization requirements for family planning drugs and devices pursuant to Attachment XXI. 5.3.1.5 Contractor shall establish and maintain a generic drug Maximum Allowable Cost (MAC) dispute resolution process, subject to approval by the Department. The MAC dispute resolution process shall enable pharmacies to report pricing disputes to the Contractor up to 60 days from the claim date and the Contractor is required to resolve the pricing dispute within 21 days by adjusting the reimbursement rate to represent the acquisition cost of the drug, or by informing the pharmacy of alternative generic equivalent products that can be purchased at or below the Contractor’s existing MAC price.

Pharmacy Requirements. The Contractor shall provide pharmacy benefits in accordance with this section in addition to other requirements specified in this contract. Pharmacy benefit requirements shall include, but not be limited to: A. State-of-the-art, online and real-time rules-based point-of-sale (POS) Claims processing services with prospective drug utilization review including an accounts receivable process; B. Retrospective utilization review services; C. Formulary and non-formulary services, including prior authorization services; D. Pharmacy provider relations and call center services, in addition to Provider Services specified elsewhere; E. Seamless interfaces with the information systems of the Commonwealth and as needed, any related vendors; and F. Coverage for all drugs for which a federal rebate is available per 42 USC § 1396r-8 and has been provided by DMS.

Pharmacy Requirements. 31.2 Formulary and Non-Formulary Services 31.3 Pharmacy Claims Administration 31.4 Pharmacy Rebate Administration 31.5 Pharmacy Program Management 31.6 Pharmacy Provider Relations and Prior Authorizations

Pharmacy Requirements