806 KAR 17:250. Notification requirements

for drug benefits.

 

      RELATES TO: KRS 304.17A-505, 304.17A-535

      STATUTORY AUTHORITY: KRS 304.2-110(1),

304.17A-565

      NECESSITY, FUNCTION, AND CONFORMITY: KRS

304.2-110(1) authorizes the executive director 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 executive director 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 enrollee:

      (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). (27 Ky.R. 2007;

Am. 2539; 2781; eff. 4-9-2001; 34 Ky.R. 651; 985; eff. 12-7-2007.)