806 KAR 17:250. Notification requirements for drug benefits

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).