Letter to CMS - Medicaid Managed Care Policies - Agency for ...

Standard XV: Immunizations, Pregnancy, Drugs & Transportation
CONTRACT
SECTION
Chapter 465, F.S.
s. 409.91195, F.S.
CC-V.H.16.a
CC-V.H.16.a.1–16.a.5
21. Prescribed
Drugs: PBA
CC-V.H.16.b
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
class.
• Makes available those drugs and dosage
forms listed in its PDL.
• Does not arbitrarily deny or reduce the
amount, duration or scope of prescriptions
solely based on the enrollee’s diagnosis, type
of illness or condition.
• May place appropriate limits on prescriptions
based on criteria such as medical necessity, or
for the purpose of utilization control, provided
the health plan reasonably expects said limits
to achieve the purpose of the prescribed drug
services set forth in the Medicaid State Plan.
• Makes available those drugs not on its PDL,
when requested and approved, if the drugs on
the PDL have been used in a step therapy
sequence or when other medical
documentation is provided.
• Submits an updated PDL to BMHC and the
Bureau of Pharmacy Services by October 1 of
each Contract year, and provides thirty (30)
days’ written notice of any changes.
If the health plan adopts the Medicaid PDL, the health
plan is exempt from such reporting.
Antiretroviral agents are not subject to the PDL.
The health plan may delegate any or all functions to
one (1) or more pharmacy benefits administrators
(PBA). Before entering into a subcontract, the health
plan works with the Agency’s fiscal agent.
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XV_F2_07_11
Yes
No
N/A
Met
Partially Met
Not Met
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