R9-22-209. Pharmaceutical Services

A. An inpatient or outpatient provider, including a hospital, clinic, other appropriately licensed health care facility, and pharmacy may provide covered pharmaceutical services. B. The Administration or a contractor shall require a provider to make pharmaceutical services: 1. Available during customary business hours, and 2. Located within reasonable travel distance of a member’s residence. C. Pharmaceutical services are covered if: 1. Prescribed for a member by the member’s primary care provider, attending physician, practitioner, or dentist; 2. Prescribed by a specialist upon referral from the primary care provider or attending physician; or 3. The contractor or its designee authorizes the service. D. The following limitations apply to pharmaceutical services: 1. A medication personally dispensed by a physician, dentist, or a practitioner within the individual’s scope of practice is not covered, except in geographically remote areas where there is no participating pharmacy or if accessible pharmacies are closed. 2. A new prescription or refill in excess of a 30 day supply is not covered unless: a. The member will be out of the provider’s service area for an extended period of time and the prescription is limited to the extended time period, not to exceed a 90 day supply; or b. The Contractor authorizes the prescription for an extended time period not to exceed a 90-day supply. 3. An over-the-counter medication, in place of a covered prescription medication, is covered only if the over-thecounter medication is appropriate, equally effective, safe, and less costly than the covered prescription medication. E. A contractor shall monitor and ensure sufficient services to prevent any gap in the pharmaceutical regimen of a member who requires a continuing or complex regimen of pharmaceutical treatment to restore, improve, or maintain physical well being.