RELATES TO:
KRS
304.17A-505,
304.17A-535
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
304.2-110(1) authorizes the
commissioner to promulgate administrative regulations necessary for or as an
aid to the effectuation of any provision of the Kentucky Insurance Code, as
defined in
KRS
304.1-010.
KRS
304.17A-565 requires the commissioner to
enforce and carry out the provisions of
KRS
304.17A-500 to
304.17A-570
by promulgating necessary administrative regulations. This administrative
regulation establishes notification requirements of a managed care plan if a
prescription medication is removed from its drug formulary, a supply amount of
a prescription is changed, or prior authorization is added for a prescription
medication.
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; or
2. 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 en-rollee:
(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).
