Michigan Laws 500.3406t – Synchronizing insured’s or enrollee’s multiple maintenance prescription drugs
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Terms Used In Michigan Laws 500.3406t
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: means an individual who is entitled to receive health services under a health insurance contract, unless the context requires otherwise. See Michigan Laws 500.116
- Health maintenance organization: means that term as defined in section 3501. See Michigan Laws 500.106
- insured: as used in this chapter , shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein. See Michigan Laws 500.3462
- Insurer: means an individual, corporation, association, partnership, reciprocal exchange, inter-insurer, Lloyds organization, fraternal benefit society, or other legal entity, engaged or attempting to engage in the business of making insurance or surety contracts. See Michigan Laws 500.106
- Rate: means the cost of insurance per payroll before adjustment for an individual insured's size, exposure, or loss experience. See Michigan Laws 500.2402
- state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories belonging to the United States; and the words "United States" shall be construed to include the district and territories. See Michigan Laws 8.3o
(1) An insurer that delivers, issues for delivery, or renews in this state an expense-incurred hospital, medical, or surgical group or individual policy or certificate that provides prescription drug coverage, or a health maintenance organization that offers a group or individual contract that provides prescription drug coverage, shall provide a program for synchronizing multiple maintenance prescription drugs for an insured or enrollee if both of the following are met:
(a) The insured or enrollee, the insured’s or enrollee’s physician, and a pharmacist agree that synchronizing the insured’s or enrollee’s multiple maintenance prescription drugs for the treatment of a chronic long-term care condition is in the best interests of the insured or enrollee for the management or treatment of a chronic long-term care condition.
(b) The insured’s or enrollee’s multiple maintenance prescription drugs meet all of the following requirements:
(i) Are covered by the policy, certificate, or contract described in this section.
(ii) Are used for the management and treatment of a chronic long-term care condition and have authorized refills that remain available to the insured or enrollee.
(iii) Except as otherwise provided in this subparagraph, are not controlled substances included in schedules 2 to 5 under sections 7214, 7216, 7218, and 7220 of the public health code, 1978 PA 368, MCL 333.7214, 333.7216, 333.7218, and 333.7220. This subparagraph does not apply to anti-epileptic prescription drugs.
(iv) Meet all prior authorization requirements specific to the maintenance prescription drugs at the time of the request to synchronize the insured’s or enrollee’s multiple maintenance prescription drugs.
(v) Are of a formulation that can be effectively split over required short fill periods to achieve synchronization.
(vi) Do not have quantity limits or dose optimization criteria or requirements that will be violated when synchronizing the insured’s or enrollee’s multiple maintenance prescription drugs.
(2) An insurer or health maintenance organization described in subsection (1) shall apply a prorated daily cost-sharing rate for maintenance prescription drugs that are dispensed by an in-network pharmacy for the purpose of synchronizing the insured’s or enrollee’s multiple maintenance prescription drugs.
(3) An insurer or health maintenance organization described in subsection (1) shall not reimburse or pay any dispensing fee that is prorated. The insurer or health maintenance organization shall only pay or reimburse a dispensing fee that is based on each maintenance prescription drug dispensed.