Cal. Code Regs. Tit. 22, § 53854 - Pharmaceutical Services and Prescribed Drugs
(a) Each plan in a designated region shall at
a minimum, make available to members during the hours of operation of each
member's primary care service site, either directly or through subcontracts,
the services of pharmacies and pharmacists in accordance with title 22, CCR,
section 53214.
(1) Pharmaceutical services shall, at a
minimum, be available to members during established service site
hours.
(2) When the course of
treatment provided to a member by a contracting provider under emergency
circumstances requires the use of drugs, a sufficient quantity of such drugs
will be provided to the member to last until the member can reasonably be
expected to have a prescription filled.
(3) Plans shall establish and document the
availability of after hours nonemergency pharmacy services. Plans shall make
available by telephone information regarding the availability, location and
hours of operation of pharmacies providing such services.
(b) Prescribed drugs shall be provided to
members by licensed pharmacies and shall be reimbursed by the plan in which the
member is enrolled. Professional standards reflected by reasonable and current
prescribing practices, based on reference to current medical literature and
consultation with provider organizations, academic and professional
specialists, shall be met, including but not limited to Title 16, sections
1707.1,
1707.2, and
1707.3.
(c) Prescribed drugs may include the
provision of pre-packaged drugs ordered by a physician and dispensed by a
pharmacist or other appropriately licensed individuals affiliated with the plan
after the plan has obtained written approval from the department to operate in
this manner.
(d) Except for drugs
specifically excluded from the contract, any drug covered by the Medi-Cal
Program shall be available from the plan when medically necessary. This shall
not be construed to require a plan to include in its formulary every drug
listed on the Medi-Cal formulary, or to prevent a plan from performing
appropriate utilization review to determine the most suitable drug therapy for
a particular medical condition. The plan shall not refuse to dispense or pay
for Medi-Cal covered drugs, while pursuing the resolution of a dispute with the
department over the plan's reimbursement for drugs, coverage of drugs, or for
any other issue relating to covered drugs.
Notes
2. Repealer of section and NOTE and new section and NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
3. Amendment of subsections (a)(1) and (d) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).
Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 14087.3, 14087.4, 14132, 14133 and 14133.1, Welfare and Institutions Code.
2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
3. Amendment of subsections (a)(1) and (d) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).
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