500.3406t Synchronizing insured's or enrollee's multiple maintenance prescription drugs.
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500.3406t Synchronizing insured's or enrollee's multiple maintenance prescription drugs.
Sec. 3406t.
(1)An insurer that delivers, issues for delivery, or renews in this state an expense-incurred hospital, medical, or surgical group or individual policy or certificate that provides prescription drug coverage, or a health maintenance organization that offers a group or individual contract that provides prescription drug coverage, shall provide a program for synchronizing multiple maintenance prescription drugs for an insured or enrollee if both of the following are met:
(a)The insured or enrollee, the insured's or enrollee's physician, and a pharmacist agree that synchronizing the insured's or enrollee's multiple maintenance prescription drugs for the treatment of a chronic long-term care condition is in the best interests of the insured or enrollee for the management or treatment of a chronic long-term care condition.
(b)The insured's or enrollee's multiple maintenance prescription drugs meet all of the following requirements:
(i)Are covered by the policy, certificate, or contract described in this section.
(ii)Are used for the management and treatment of a chronic long-term care condition and have authorized refills that remain available to the insured or enrollee.
(iii)Except as otherwise provided in this subparagraph, are not controlled substances included in schedules 2 to 5 under sections 7214, 7216, 7218, and 7220 of the public health code, 1978 PA 368, MCL 333.7214, 333.7216, 333.7218, and 333.7220. This subparagraph does not apply to anti-epileptic prescription drugs.
(iv)Meet all prior authorization requirements specific to the maintenance prescription drugs at the time of the request to synchronize the insured's or enrollee's multiple maintenance prescription drugs.
(v)Are of a formulation that can be effectively split over required short fill periods to achieve synchronization.
(vi)Do not have quantity limits or dose optimization criteria or requirements that will be violated when synchronizing the insured's or enrollee's multiple maintenance prescription drugs.
(2)An insurer or health maintenance organization described in subsection
(1)shall apply a prorated daily cost-sharing rate for maintenance prescription drugs that are dispensed by an in-network pharmacy for the purpose of synchronizing the insured's or enrollee's multiple maintenance prescription drugs.
(3)An insurer or health maintenance organization described in subsection
(1)shall not reimburse or pay any dispensing fee that is prorated. The insurer or health maintenance organization shall only pay or reimburse a dispensing fee that is based on each maintenance prescription drug dispensed.
History: Add. 2016, Act 38 , Imd. Eff. Mar. 15, 2016
Compiler's Notes: Enacting section 1 of Act 38 of 2016 provides:"Enacting section 1. This amendatory act applies to policies, certificates, and contracts delivered, executed, issued, amended, adjusted, or renewed in this state, or outside of this state if covering residents of this state, beginning 365 days after the date this amendatory act is enacted into law."
Popular Name: Act 218