Section 405 IAC 14-2-61 - Drug coverageAuthority: IC 12-15-1-10
Affected: IC 12-15-5; IC 12-15-12
Sec. 61.
(a) An MCO shall follow the office's Statewide Uniform Preferred Drug List (SUPDL).(b) An MCO shall have a policy allowing at least a seventy-two (72) hour emergency supply of a covered outpatient prescription drug, as required under 42 U.S.C. 1396r- 8(d)(5)(B), without needing prior authorization.(c) An MCO shall use a pharmacy and therapeutics committee that meets regularly to make recommendations for changes to drugs not on the SUPDL.(d) Under CMS-2390-F and 42 CFR 438.210, an MCO shall demonstrate prescription drug coverage consistent with the amount, duration, and scope of the FFS program. This includes the following:(1) The MCO shall engage with the office to develop medically necessary prior authorization criteria for Indiana Medicaid and CHIP enrollees.(2) The MCO shall carry out the universal criteria in subdivision (1) into the MCO's program and may not use more restrictive criteria, including quantitative and nonquantitative treatment limits.(e) An MCO shall maintain an over-the-counter (OTC) drug formulary and pharmacy supplements formulary the same items included in the FFS OTC drug formulary, and pharmacy supplements formulary and as updated by the drug utilization review board. Additions to the MCO OTC drug formulary are required to only be from participating rebating labelers.(f) An MCO may choose to contract with the office's pharmacy benefit manager contractor for pharmacy claims processing.(g) An MCO shall carry out a process to allow member access to medically necessary non-SUPDL drugs.(h) Legend drugs may be delivered outside the capitated managed care arrangement if they: (1) meet the requirements at 405 IAC 5-24-3; and(2) are determined by the office to be better delivered through FFS and not to be included in the capitated managed care arrangement due to clinical or financial reasons based on the considerations listed in subsection (i).(i) The office may determine drugs in subsection (h) based on the following:(1) Substantial supplemental drug rebates.(2) Potential and actual prior authorization criteria alignment issues.(3) Correlating diagnosis related group and hospital assessment fee carve-outs.(4) Impact planning: (A) orphan drugs or orphan-like drugs;(B) capitation rate allocation based on: (i) capitation payment waste; and(ii) disproportionate capitation allocation; and(C) MCO solvency and related issues based on: (i) reinsurance costs and availability;(ii) disproportionate use and reimbursement across plans; and(j) MCOs may request the office to review eligible drugs detailed in subsection (h) to be delivered outside the capitated managed care arrangement.Office of the Secretary of Family and Social Services; 405 IAC 14-2-61; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA