Section 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(1) 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.(2) 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.(3) 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.(4) 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.(5) Any dispensing fee shall not be prorated and shall be based on an individual prescription filled or refilled.Amended by 2015 Ky. Acts ch. 39,§ 1, eff. 1/1/2016.Effective:7/12/2006
Created 2006, Ky. Acts ch. 213, sec. 1, effective7/12/2006.