Pharmacy. The Contractor must establish policies and procedures to comply with the Division’s Prior Authorization criteria in accordance with the PDL guidance for the drugs listed on the PDL. The Contractor may approve non-preferred drugs when one of the following Prior Authorization criteria is satisfied: a. Member experiences an adverse event(s) or reaction(s) to preferred medications; or b. Contraindications to preferred medications (i.e. drug interaction, existing medical condition preventing the use of preferred medications). c. The Contractor must establish criteria and coverage policies for drugs not listed on the PDL, which must be approved by the Division. The Contractor must ensure that decisions regarding policies and procedures for prescription drugs are made in a clinically sound manner.
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