Kentucky Statutes 304.17A-535 – Drug utilization waiver program — Limitations on generic substitution — Application to drug formulary
Current as of: 2024 | Check for updates
|
Other versions
(1) A managed care plan shall include a drug utilization review program, the primary emphasis of which shall be to enhance quality of care for enrollees by assuring appropriate drug therapy within the health care provider‘s legally authorized scope of practice, that:
(a) Includes the following:
1. Retrospective review of prescription drugs furnished to enrollees;
2. Education of health care providers and enrollees regarding the appropriate use of prescription drugs; and
3. Ongoing periodic examination of data on outpatient prescription drugs to ensure quality therapeutic outcomes for enrollees; and
(b) Complies with KRS § 304.17A-163 and KRS § 304.17A-1631.
(2) The drug utilization review program shall utilize the following to effectuate the purposes of subsection (1) of this section:
(a) Relevant clinical criteria and standards for drug therapy;
(b) Nonproprietary criteria and standards developed and revised through input from participating health care providers;
(c) Intervention that focuses on improving therapeutic outcomes; and
(d) Measures to ensure the confidentiality of the relationship between an enrollee and a health care provider.
(3) When, in the professional opinion of a provider with prescriptive authority, the provider determines that generic substitution of a pharmaceutical product is medically inappropriate, the provider shall prescribe the pharmaceutical product the provider determines medically appropriate with the indication “Do Not Substitute,” and no substitution shall be made without the provider’s approval.
(4) A managed care plan that restricts pharmacy benefits to a drug formulary shall have an exceptions policy through which the managed care plan may cover a prescription drug not included on the formulary.
Effective: January 1, 2023
History: Amended 2022 Ky. Acts ch. 19, sec. 4, effective January 1, 2023. — Amended
2000 Ky. Acts ch. 500, sec. 9, effective July 14, 2000. — Created 1998 Ky. Acts ch.
496, sec. 32, effective April 10, 1998.
Legislative Research Commission Note (1/1/2023). 2022 Ky. Acts ch. 19, sec. 13, provides that the amendments made to this statute shall apply to health plans delivered, issued for delivery, or renewed on or after January 1, 2023.
(a) Includes the following:
Terms Used In Kentucky Statutes 304.17A-535
- Managed care: means systems or techniques generally used by third-party payors or their agents to affect access to and control payment for health care services and that integrate the financing and delivery of appropriate health care services to covered persons by arrangements with participating providers who are selected to participate on the basis of explicit standards for furnishing a comprehensive set of health care services and financial incentives for covered persons using the participating providers and procedures provided for in the plan. See Kentucky Statutes 304.17A-005
- provider: means any:
(a) Advanced practice registered nurse licensed under KRS Chapter 314. See Kentucky Statutes 304.17A-005 - Statute: A law passed by a legislature.
1. Retrospective review of prescription drugs furnished to enrollees;
2. Education of health care providers and enrollees regarding the appropriate use of prescription drugs; and
3. Ongoing periodic examination of data on outpatient prescription drugs to ensure quality therapeutic outcomes for enrollees; and
(b) Complies with KRS § 304.17A-163 and KRS § 304.17A-1631.
(2) The drug utilization review program shall utilize the following to effectuate the purposes of subsection (1) of this section:
(a) Relevant clinical criteria and standards for drug therapy;
(b) Nonproprietary criteria and standards developed and revised through input from participating health care providers;
(c) Intervention that focuses on improving therapeutic outcomes; and
(d) Measures to ensure the confidentiality of the relationship between an enrollee and a health care provider.
(3) When, in the professional opinion of a provider with prescriptive authority, the provider determines that generic substitution of a pharmaceutical product is medically inappropriate, the provider shall prescribe the pharmaceutical product the provider determines medically appropriate with the indication “Do Not Substitute,” and no substitution shall be made without the provider’s approval.
(4) A managed care plan that restricts pharmacy benefits to a drug formulary shall have an exceptions policy through which the managed care plan may cover a prescription drug not included on the formulary.
Effective: January 1, 2023
History: Amended 2022 Ky. Acts ch. 19, sec. 4, effective January 1, 2023. — Amended
2000 Ky. Acts ch. 500, sec. 9, effective July 14, 2000. — Created 1998 Ky. Acts ch.
496, sec. 32, effective April 10, 1998.
Legislative Research Commission Note (1/1/2023). 2022 Ky. Acts ch. 19, sec. 13, provides that the amendments made to this statute shall apply to health plans delivered, issued for delivery, or renewed on or after January 1, 2023.