2015 Kentucky Revised Statutes CHAPTER 304 - INSURANCE CODE Subtitle 17A - Health Benefit Plans 17A.17A-165 Prescription drug coverage to include exceptions or override policy for refills of covered drugs -- Limitations and exclusions -- Program for synchronization of medications.
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304.17A-165 Prescription drug coverage to include exceptions or override
policy for refills of covered drugs -- Limitations and exclusions -Program for synchronization of medications.
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Any health benefit plan that provides benefits for prescription drugs shall
include an exceptions policy or an override policy that provides coverage for
the refill of a covered drug dispensed prior to the expiration of the insured's
supply of the drug. The insurer shall provide notice in existing written or
electronic communications to pharmacies doing business with the insurer, the
pharmacy benefit manager if applicable, and to the insured regarding the
exceptions policy or override policy. This subsection shall not apply to
controlled substances as classified by KRS Chapter 218A.
Nothing in this section shall prohibit an insurer from limiting payment to no
more than three (3) refills of a covered drug in a ninety (90) day period.
Any individual or group health benefit plan that provides benefits for
prescription drugs shall provide a program for synchronization of medications
when it is agreed among the insured, a provider, and a pharmacist that
synchronization of multiple prescriptions for the treatment of a chronic illness is
in the best interest of the patient for the management or treatment of a chronic
illness provided that the medications:
(a) Are covered by the individual or group health benefit plan:
(b) Are used for treatment and management of chronic conditions that are
subject to refills;
(c) Are not a Schedule II controlled substance or a Schedule III controlled
substance containing hydrocodone;
(d) Meet all prior authorization criteria specific to the medications at the time
of the synchronization request;
(e) Are of a formulation that can be effectively split over required short fill
periods to achieve synchronization; and
(f) Do not have quantity limits or dose optimization criteria or requirements
that would be violated in fulfilling synchronization.
To permit synchronization, an individual or group health benefit plan shall apply
a prorated daily cost-sharing rate to any medication dispensed by a network
pharmacy pursuant to this section.
Any dispensing fee shall not be prorated and shall be based on an individual
prescription filled or refilled.
Effective:January 1, 2016
History: Amended 2015 Ky. Acts ch. 39, sec. 1, effective January 1, 2016. -Created 2006 Ky. Acts ch. 213, sec. 1, effective July 12, 2006.
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