Pharmacy Services. The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.
Pharmacy Services. CONTRACTOR shall provide sufficient controls over both its contracted and employed physicians/psychiatrists to be able to ensure strict adherence to the FDC’s drug formulary. Compliance with the FDC’s DER policy is required with one exception, an appropriately qualified CONTRACTOR representative shall stand in place of FDC to review and approve or deny DER, prior to prescribing any non-formulary medications. Subsets or restricted use of the FDC’s formulary that effectively limit, in any manner, the use of the FDC’s formulary are prohibited. Additionally, all medications shall be prescribed appropriately as indicated in the current edition of Drug Facts and Comparisons and the most recent Physicians’ Desk Reference. CONTRACTOR shall not prescribe non-therapeutic doses, or change, increase or decrease medication or dosages without providing ample time for the medication to take effect as provided for in the package insert. If this occurs, CONTRACTOR shall be considered non-compliant with the provisions of care in the Contract. Should there be a requirement for use of a non-therapeutic dosage or the need to prematurely change medication or dosages, there must be appropriate clinical justification documented in the chart as well as adherence to the DER process to gain approval. Practitioners’ prescribing practices shall be tracked monthly and reported by CONTRACTOR. Prescribing practices shall also be monitored for performance measure compliance.
Pharmacy Services. The MCO must provide pharmacy-dispensed prescriptions as a Covered Service. The MCO must submit pharmacy clinical guidelines and prior authorization policies and for review and approval during Readiness Review, then after the Operational Start Date prior to any changes. In determining whether to approve these materials, HHSC will review factors such as the clinical efficacy and Members' needs. The MCO must allow pharmacies to fill prescriptions for covered drugs ordered by any licensed provider regardless of Network participation and must encourage Network pharmacies to also become Medicaid-enrolled durable medical equipment (DME) providers. The MCO is responsible for negotiating reasonable pharmacy provider reimbursement rates, including individual MCO maximum allowable cost (MAC) rates, as described in Section 22.214.171.124, "Maximum Allowable Cost Requirements." The MCO must ensure that, as an aggregate, rates comply with 42 C.F.R. Part 50, Subpart E, regarding upper payment limits.
Pharmacy Services. We reviewed historical pharmacy experience by therapeutic class for each MCP to estimate achievable generic drug dispensing rates (GDR), generic drug cost per script, and brand drug cost per script. For each therapeutic class, we estimated the impact of improvements in GDR and cost per script amounts by repricing MCP historical experience to levels achieved by other MCPs during the same time period. Antipsychotics, Antidepressants, and Anticonvulsant were excluded from this analysis. We developed pharmacy managed care efficiency adjustments by rate cell to reflect mix differences by therapeutic class due to the age, gender, and morbidity of the applicable rate cell.
Pharmacy Services. Except as provided in Section 126.96.36.199 of this Agreement, pharmacy services shall not be provided by the CONTRACTOR but shall be provided by a pharmacy benefits manager (PBM) under contract with TENNCARE. Coverage of pharmacy services is described in TennCare rules and regulations. TENNCARE does not cover pharmacy services for enrollees who are dually eligible for TennCare and Medicare.
Pharmacy Services. PHARMACY agrees to render Covered Prescription Services to Members in accordance with the terms and conditions of this Agreement. PHARMACY shall provide Prescription Services to Members for Covered Products in as reasonably timely a manner as provided to other patrons and shall not discriminate against an eligible Member.
Pharmacy Services. Except for the drugs specified in Article 4.1.4 (Clozapine, Risperidone, Olanzapine, etc.), all pharmacy services are covered by the contractor. This includes drugs prescribed by the contractor or MH/SA providers. The contractor shall only restrict or require a prior authorization for prescriptions or pharmacy services prescribed by MH/SA providers if one of the following exceptions is demonstrated:
Pharmacy Services. The PH-MCO must comply with the Department’s pharmacy services standards and requirements described in: Exhibit BBB Pharmacy Services Exhibit BBB (1) Drug Formulary Guidelines Exhibit BBB (2) Drug Utilization Review Guidelines Exhibit BBB (3) Pharmacy Denial Notice - Complete Denial Exhibit BBB (4) Pharmacy Denial Notice– Partial Approval Exhibit BBB (5) Pharmacy Denial Notice – Approval of Different Medication Exhibit BBB (6) Requirements Covering Medications Prescribed by PH-MCOs and BH-MCOs