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

Standard XV: Immunizations, Pregnancy, Drugs & Transportation
CONTRACT
SECTION
CC-V.H.16.f
CC-V.H.16.f.3
CC-V.H.16.f.3.a
CC-V.H.16.f.3.b
CC-V.H.16.f.3.c
CC-V.H.16.f.3.d
CC-V.H.16.f.3.e
CC-V.H.16.f.4
23. Prescribed
Drugs:
Providing
Brand-Name
Drugs
s. 465.025, F.S.
CC-V.H.16.g
24. PSNs ONLY:
Hemophilia
Factor-Related
Drugs
CC-V.H.16.h
25. Prescribed
Drugs: HMOs-
Hemophilia
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
Requirements.
• Submits a report annually, by August 1 of
each Contract year to BMHC, providing
survey results.
• Offers training to all new and existing
participating pharmacy locations about the
HSA requirements.
The health plan covers the cost of a brand-name drug
if the prescriber:
Writes in his/her own handwriting on the valid
prescription that the “Brand Name is Medically
Necessary;” and submits a completed “Multisource
Drug and Miscellaneous Prior Authorization” form to
the health plan indicating that the enrollee has had an
adverse reaction to a generic drug or has had, in the
prescriber’s medical opinion, better results when
taking the brand-name drug.
Hemophilia factor-related drugs identified by the
Agency for distribution through the Comprehensive
Hemophilia Disease Management Program are
reimbursed on a fee-for-service basis.
During operation of the Comprehensive Hemophilia
Disease Management Program, the health plan
coordinates the care of its enrollees with Agencyapproved
organizations and will not be responsible for
the distribution of hemophilia-related drugs
For HMOs, hemophilia factor-related drugs are
reimbursed by Medicaid on a fee-for-service
basis. The HMO coordinates the care of its enrollees
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XV_F2_07_11
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
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