Title 806 | Chapter 017 | Regulation 250
806 KAR 17:250.Notification requirements for drug benefits.
Section 1.
Definitions.(1)
"Drug formulary" means a list of prescription medications preferred for use by a managed care plan and dispensed through a participating pharmacy to an enrollee.(2)
"Enrollee" is defined in KRS 304.17A-500(5).(3)
"Maintenance prescription medication" means a prescription drug(a)
For which a managed care plan receives no less than:1.
Three (3) claims for a thirty (30) day supply within a four (4) month period of time; or2.
One (1) claim for a ninety (90) day supply within a six (6) month period of time, including a mail order prescription; and(b)
That is required for maintenance therapy as determined by the prescribing provider.(4)
"Managed care plan" is defined in KRS 304.17A-500(9).Section 2.
Notification Requirements.(1)
A managed care plan shall provide advance written notice to an enrollee of the following changes:(a)
The removal of a maintenance prescription medication from its drug formulary;(b)
A change that restricts or reduces the quantity or dosage of a prescription medication supplied when a prescription is filled; or(c)
A requirement for prior authorization of a prescription medication is added.(2)
A written notification pursuant to subsection (1) of this section shall be mailed to an enrollee:(a)
At least thirty (30) but no more than sixty (60) days prior to the effective date of a change as listed in subsection (1)(a), (b), or (c) of this section for an enrollee who is dispensed a prescription for the drug within six (6) months prior to the notification date; and(b)
Within thirty (30) days following the effective date of a change as listed in subsection (1)(a), (b), and (c) of this section for an enrollee who is dispensed a prescription for the drug after the notification date required by paragraph (a) of this subsection of this section.(3)
A written notification pursuant to subsection (1) of this section shall include:(a)
A clear explanation of the action being taken by the managed care plan;(b)
The name and phone number of a contact person to answer questions; and(c)
A description of the exceptions policy to the drug formulary pursuant to KRS 304.17A-535(4).HISTORY: (27 Ky.R. 2007; Am. 2539; 2781; eff. 4-9-2001; 34 Ky.R. 651; 985; eff. 12-7-2007; Crt eff. 2-26-2020; TAm eff. 3-10-2020.)
806 KAR 17:250.Notification requirements for drug benefits.
Section 1.
Definitions.(1)
"Drug formulary" means a list of prescription medications preferred for use by a managed care plan and dispensed through a participating pharmacy to an enrollee.(2)
"Enrollee" is defined in KRS 304.17A-500(5).(3)
"Maintenance prescription medication" means a prescription drug(a)
For which a managed care plan receives no less than:1.
Three (3) claims for a thirty (30) day supply within a four (4) month period of time; or2.
One (1) claim for a ninety (90) day supply within a six (6) month period of time, including a mail order prescription; and(b)
That is required for maintenance therapy as determined by the prescribing provider.(4)
"Managed care plan" is defined in KRS 304.17A-500(9).Section 2.
Notification Requirements.(1)
A managed care plan shall provide advance written notice to an enrollee of the following changes:(a)
The removal of a maintenance prescription medication from its drug formulary;(b)
A change that restricts or reduces the quantity or dosage of a prescription medication supplied when a prescription is filled; or(c)
A requirement for prior authorization of a prescription medication is added.(2)
A written notification pursuant to subsection (1) of this section shall be mailed to an enrollee:(a)
At least thirty (30) but no more than sixty (60) days prior to the effective date of a change as listed in subsection (1)(a), (b), or (c) of this section for an enrollee who is dispensed a prescription for the drug within six (6) months prior to the notification date; and(b)
Within thirty (30) days following the effective date of a change as listed in subsection (1)(a), (b), and (c) of this section for an enrollee who is dispensed a prescription for the drug after the notification date required by paragraph (a) of this subsection of this section.(3)
A written notification pursuant to subsection (1) of this section shall include:(a)
A clear explanation of the action being taken by the managed care plan;(b)
The name and phone number of a contact person to answer questions; and(c)
A description of the exceptions policy to the drug formulary pursuant to KRS 304.17A-535(4).HISTORY: (27 Ky.R. 2007; Am. 2539; 2781; eff. 4-9-2001; 34 Ky.R. 651; 985; eff. 12-7-2007; Crt eff. 2-26-2020; TAm eff. 3-10-2020.)