Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006Req #POS.228POS.229POS.230POS.231POS.2326. Pharmacy Point-of-Sale (POS)Description of RequirementAbility to support emergency PA capability (as defined by BMS,using NCPDP standards). (This requirement is the same as a 3-dayemergency fill for drugs that require a prior authorization).Ability to provide a mechanism for the Vendor and the State toenter Prior Authorization data, based on role-based security asdetermined by BMS.Ability to provide on-line access to all prior authorizationinformation.Ability to accept on-line, real-time entry and update of PAdeterminations.Ability to utilize prior authorization restrictions to include, but notYESwithoutcustomizationXlimited to:POS.233 Drug data (e.g., NDC (9 to 11 digits), HIC, GCN sequence) XPOS.234 Member data XPOS.235 Provider data XPOS.236 Day specific, or span dates of the prior authorization XPOS.237 Frequency restrictions XPOS.238Dollar/unit dispensing limitations (the POS should have theability to limit prescriptions based on a dollar threshold amountand to limit prescriptions based on dispensed units)POS.239 Other as identified by BMS during DDI and accepted viaXformal change controlPOS.240 Ability to link to eligibility data when reviewing the PA request. XPOS.241 Ability to automatically identify and update active or pended PArecords when a reference file has been updated (e.g., drug code,drug category). (Claims are not pended in the Pharmacy POSsystem. BMS expects the POS system to be capable of updatingthe PA parameter (generic sequence number, generic code, etc)when the drug file changes the parameter, so that PA requirementsand processing are maintained).XPOS.242POS.243Ability to require and process PA for service to Member in LTC.(The same level of editing/auditing that are done for pharmacyclaims outside of a LTC, but the LTC would be a separateeligibility group with distinct PA requirements).Ability to "grandfather" Members on identified services when anew PA requirement is identified. (BMS currently uses a PreferredDrug List. In the past, it has been desired to allow current users ofa drug to continue, but new users require a prior authorization. Anexample is Zyprexa. Current users were allowed to continue toreceive this drug, but new users were required to receive a priorauthorization for coverage of the drug).POS.244 Ability to add back the unused units if a claim is reversed XPOS.245 Ability to generate denial notices to Members. XPOS.246 17. Prior Authorization - Automated Prior AuthorizationPOS.247 Ability to provide automated approval of authorizations basedupon any Federal, State, and BMS policy and guidelines, for use indetermining if pre-established criteria for selected drugs have beenmet. The data queried is expected to include diagnosis codes,procedure codes and pharmacy claims data (for both fee-forserviceand encounter data).XXXXXXXXYESwithcustomizationNOunabletoprovide14.2-84