§ 53854. Pharmaceutical Services and Prescribed Drugs.

(a) Each plan in a designated region shall at a minimum, make available to members during the hours of operation of each member's primary care service site, either directly or through subcontracts, the services of pharmacies and pharmacists in accordance with title 22, CCR, section 53214.

(1) Pharmaceutical services shall, at a minimum, be available to members during established service site hours.

(2) When the course of treatment provided to a member by a contracting provider under emergency circumstances requires the use of drugs, a sufficient quantity of such drugs will be provided to the member to last until the member can reasonably be expected to have a prescription filled.

(3) Plans shall establish and document the availability of after hours nonemergency pharmacy services. Plans shall make available by telephone information regarding the availability, location and hours of operation of pharmacies providing such services.

(b) Prescribed drugs shall be provided to members by licensed pharmacies and shall be reimbursed by the plan in which the member is enrolled. Professional standards reflected by reasonable and current prescribing practices, based on reference to current medical literature and consultation with provider organizations, academic and professional specialists, shall be met, including but not limited to Title 16, sections 1707.1, 1707.2, and 1707.3.

(c) Prescribed drugs may include the provision of pre-packaged drugs ordered by a physician and dispensed by a pharmacist or other appropriately licensed individuals affiliated with the plan after the plan has obtained written approval from the department to operate in this manner.

(d) Except for drugs specifically excluded from the contract, any drug covered by the Medi-Cal Program shall be available from the plan when medically necessary. This shall not be construed to require a plan to include in its formulary every drug listed on the Medi-Cal formulary, or to prevent a plan from performing appropriate utilization review to determine the most suitable drug therapy for a particular medical condition. . The plan shall not refuse to dispense or pay for Medi-Cal covered drugs, while pursuing the resolution of a dispute with the department over the plan's reimbursement for drugs, coverage of drugs, or for any other issue relating to covered drugs.

HISTORY

1. New section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).

2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).

3. Amendment of subsections (a)(1) and (d) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).

Note

Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 14087.3, 14087.4, 14132, 14133 and 14133.1, Welfare and Institutions Code.