Common use of Dispensing and Monitoring Requirements Clause in Contracts

Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations. For any drugs which require prior authorization, the Contractor shall provide a response by telephone or other telecommunication device within twenty-four (24) hours of a request for prior authorization. Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour Emergency EXHIBIT 1 SCOPE OF WORK supply of a covered outpatient prescription drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. The Contractor may require prior authorization requirements, such as general member information, a justification of need for drug related to the medical needs of the member and a planned course of treatment, if applicable, as related to the quantity of drug provided and duration of treatment. The Contractor will be required to have a process in place to allow member access to medically necessary non-preferred (non-formulary) drugs. To conform to 42 CFR 437-438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization criteria for access to a prescription drug is developed, the Contractor’s criteria must be consistent with the amount, duration and scope of that criteria and may not be more stringent. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. These criteria and edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be posted online, linked to the ▇▇▇▇▇://▇▇▇.▇▇.▇▇▇/medicaid/ website. Additionally, the Contractor shall implement a retrospective drug utilization program to analyze for drugs or specific groups of drugs to document utilization trends and intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost-effective care. The Contractor must also implement a program to identify and report fraud and abuse among providers and members.

Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations. For any drugs which require prior authorization, the EXHIBIT 1 SCOPE OF WORK Contractor shall provide a response by telephone or other telecommunication device within twenty-four (24) hours of a request for prior authorization. Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour Emergency EXHIBIT 1 SCOPE OF WORK supply of a covered outpatient prescription drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. The Contractor may require prior authorization requirements, such as general member information, a justification of need for drug related to the medical needs of the member and a planned course of treatment, if applicable, as related to the quantity of drug provided and duration of treatment. The Contractor will be required to have a process in place to allow member access to medically necessary non-preferred (non-formulary) drugs. To conform to 42 CFR 437-438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization criteria for access to a prescription drug is developed, the Contractor’s criteria must be consistent with the amount, duration and scope of that criteria and may not be more stringent. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. These criteria and edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be posted online, linked to the ▇▇▇▇▇://▇▇▇.▇▇.▇▇▇/medicaid/ website. Additionally, the Contractor shall implement a retrospective drug utilization program to analyze for drugs or specific groups of drugs to document utilization trends and intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost-effective care. The Contractor must also implement a program to identify and report fraud and abuse among providers and members.

Dispensing and Monitoring Requirements. The Contractor shall administer pharmacy benefits in accordance with all applicable state and federal laws and regulations. For any drugs which require prior authorization, the Contractor shall provide a response by telephone or other telecommunication device within twenty-four (24) hours of a request for prior authorizationauthorization per 42 CFR 438.210(d)(3). Additionally, the Contractor shall provide for the dispensing of at least a seventy-two (72) hour Emergency EXHIBIT 1 SCOPE OF WORK supply of a covered outpatient prescription drug, as required under 42 U.S.C 1396r- 8(d)(5)(B), without prior authorization. The Contractor may require prior authorization requirementsrequirements in compliance with 42 CFR 438.3(s)(6) and section 1927(d)(5) of the Social Security Act, such as general member information, a justification of need for drug related to the medical needs of the member and a planned course of treatment, if applicable, as related to the quantity of drug provided and duration of treatment. The Contractor will be required to have a process in place to allow member access to medically necessary non-non- preferred (non-formulary) drugs. To conform to 42 CFR 437-438.3(s) and the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F), once universal medically necessary prior authorization criteria for access to a prescription drug is developed, the Contractor’s criteria must be consistent with the amount, duration and scope of that criteria and may not be more stringent. The Contractor shall provide online and real-time rules-based point-of-sale (POS) claims processing for pharmacy benefits. In accordance with 42 CFR Part 456, subpart K and 42 CFR 438.3(s)(4), the Contractor shall operate drug utilization review as described in this section. The Contractor shall maintain prospective drug utilization review edits and apply these edits at the POS. These criteria and edits must be reviewed and approved by the DUR Board prior to implementation. The Contractor shall maintain prospective drug utilization review criteria and edits for covered outpatient drugs that the Contractor limits to medical benefit coverage. All criteria and edits applied to covered outpatient drugs for the pharmacy benefit and/or the medical benefit will be posted online, linked to the ▇▇▇▇▇://▇▇▇.▇▇.▇▇▇/medicaid/ website. Additionally, the Contractor shall implement a retrospective drug utilization program to analyze for drugs or specific groups of drugs to document utilization trends and intervene with identified prescriber practice outliers leading to educational interventions which emphasize clinically sound and cost-effective care. The Contractor must also implement a program to identify and report fraud and abuse among providers and members. Additionally, the Contractor shall implement retrospective drug use review to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists and individuals receiving benefits, or associated with specific drugs or groups of drugs. 1. Administration of all criteria, common or independent, shall be performed by the Contractor or its subcontracted PBM. The MCE shall regularly report findings on audits performed and outcomes completed by the PBM on providers 2. The MCE shall regularly report findings on audits performed and outcomes completed by the MCE on its PBM 3. The MCE shall immediately report, to FSSA: a. Claims processing outages experienced by the MCE and/or its PBM b. The MCE shall provide a root cause analysis of the outage to the Office in a timely manner c. Claims processing errors i. The MCE shall provide a root cause analysis of the claims processing error to the Office in a timely manner