205.5514 Department’s duties regarding state pharmacy benefit management.
653 words·~3 min read·
/ky/chapter-205/205-5514A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
(1)The department shall:
(a)Establish a single preferred drug list to be used by the state pharmacy benefit
manager for each managed care organization with whom the department
contracts for the delivery of Medicaid services; and
(b)Promulgate administrative regulations that establish:
1. Reimbursement methodologies; and
2. Dispensing fees which may take into account applicable guidance by the
Centers for Medicare and Medicaid Services and which may, to the
extent permitted under federal law, vary by pharmacy type, including
rural and independently owned pharmacies, chain pharmacies, and
pharmacies owned or contracted by a health care facility that is
registered as a covered entity pursuant to 42 U.S.C. sec. 256b.
Reimbursement methodologies established by administrative regulations shall
not discriminate against pharmacies owned or contracted by a health care
facility that is registered as a covered entity pursuant to 42 U.S.C. sec. 256b,
to the extent allowable by the Centers for Medicare and Medicaid Services.
(2)The reimbursement methodologies and dispensing fees established by the
department pursuant to subsection
(1)of this section shall be used by the state
pharmacy benefit manager for each managed care organization with whom the
department contracts for the delivery of Medicaid services.
(3)The state pharmacy benefit manager shall administer, adjudicate, and reimburse
pharmacy benefit claims submitted by pharmacies to the state pharmacy benefit
manager in accordance with:
(a)The terms of any contract between a health care facility that is registered as a
covered entity pursuant to 42 U.S.C. sec. 256b and a Medicaid managed care
organization;
(b)The terms and conditions of the contract between the state pharmacy benefit
manager and the Commonwealth; and
(c)The reimbursement methodologies and dispensing fees established by the
department, pursuant to subsection
(1)of this section.
(4)The following shall apply to the state pharmacy benefit manager, the contract
between the state pharmacy benefit manager and the department, and, where
applicable, any contract between the state pharmacy benefit manager and a
pharmacy:
(a)The department shall be responsible for reviewing and shall approve or deny:
1. Any contract, any change in the terms of a contract, or suspension or
termination of a contract between the state pharmacy benefit manager
and a pharmacy licensed under KRS Chapter 315; and
2. Any contract, any change in the terms of a contract, or suspension or
termination of a contract between the state pharmacy benefit manager
and an entity that contracts on behalf of a pharmacy licensed under KRS
Chapter 315;
(b)The state pharmacy benefit manager shall comply with KRS 304.9-053,
304.9-054, and 304.9-055;
(c)After December 1, 2020, the state pharmacy benefit manager shall not enter
into, renew, extend, or amend a national contract with any pharmacy that is
inconsistent with:
1. The terms and conditions of the contract between the state pharmacy
benefit manager and the Commonwealth; or
2. The reimbursement methodologies and dispensing fees established by
the department, pursuant to subsection
(1)of this section;
(d)1. When creating or establishing a pharmacy network for a managed care
organization with whom the department contracts for the delivery of
Medicaid services, the state pharmacy benefit manager shall not
discriminate against any pharmacy or pharmacist that is:
a. Located within the geographic coverage area of the managed care
organization; and
b. Willing to agree to or accept reasonable terms and conditions
established by the state pharmacy benefit manager, or other
administrator for network participation, including obtaining
preferred participation status.
2. Discrimination prohibited by this paragraph shall include denying a
pharmacy the opportunity to participate in a pharmacy network at
preferred participation status; and
(e)A contract between the state pharmacy benefit manager and a pharmacy shall
not release the state pharmacy benefit manager from the obligation to make
any payments owed to the pharmacy for services rendered prior to the
termination of the contract between the state pharmacy benefit manager and
the pharmacy or removal of the pharmacy from the pharmacy network.