REQUIREMENTS REPONSE

For each requirement, Contractors shall select whether the proposed solution meets the requirement out of the box, with configuration, or with customization. Contractors may provide further explanation to their response for each requirement in Column H.

a) Distributing therapeutic categories to the pharmacy team for discussion in meetings at least fifty (50) calendar days prior to the scheduled meeting

b) Creating presentation material for the meeting

c) Providing all materials to the Pharmacy and Therapeutics Committee members, regardless of size, produced by the Contractor or SCDHHS or submitted by interested stakeholders (e.g., manufacturers, providers, advocacy organizations) at least five (5) business days before the scheduled meeting

d) Preparing and distributing (posting to website) meeting agendas to committee members thirty (30) calendar days ahead of the meeting

e) Generating meeting minutes and forwarding them to SCDHHS within five (5) business days after the meeting

f) Facilitating the clinical topics for the Pharmacy and Therapeutics Committee meeting

25 Functional Pharmaceutical & Therapeutic Committee P&T The Contractor shall oversee and implement Pharmacy and Therapeutics Committee meetings, as well as, but not limited to:

a) Posting meeting minutes on the SCDHHS-approved website after meeting minute approval at the next meeting

b) Coordinating with drug manufacturers to present at meetings per SCDHHS-guidelines

c) Establishing online teleconferencing for meetings

d) Managing meeting RSVPs, determining a quorum for all meetings a minimum of two (2) business days prior to the meeting, communicating with the Pharmacy Team

e) Emailing a summary of pharmacy and therapeutic decision points to distribute to the MCOs and the committee members to aid in the implementation of changes within five (5) business days

a) Providing intervention materials to SCDHHS a minimum of fifteen (15) calendar days prior to the Drug Utilization Review Board meeting

b) Creating presentation material for the meeting (e.g. trends in claim data, outreach Initiatives, and themed discussions)

c) Providing all materials to the Drug Utilization Review Board members, regardless of size, produced by the Contractor or SCDHHS or submitted by interested stakeholders (e.g., manufacturers, providers, advocacy organizations) at least five (5) business days before the scheduled meeting

d) Preparing and distributing meeting agendas to Drug Utilization Review Board members at least fifteen (15) calendar days before next meeting 59 Functional Drug Utilization Review DUR Board The Contractor shall oversee and implement Drug Utilization Review Board meetings, as well as, but not limited to:

a) Coordinating requested updates to meeting agendas per Drug Utilization Review Board member feedback

b) Generating meeting minutes and forwarding them to SCDHHS within five (5) business days after the meeting

c) Posting meeting minutes on the SCDHHS-approved website

d) Managing meeting invitations and ensuring attendee list is up to date

e) Reserving physical meeting space and establishing virtual meeting links for each meeting

67 Functional Drug Utilization Review DUR Annual Report The annual drug utilization review report process includes:

a) Preparing and submitting report to SCDHHS at least thirty (30) calendar days prior to the deadline for submission to CMS

b) Updating the report based on any comments made by CMS

Components of the prior authorization program include, but are not limited to:

a) Implementation of the operational processes to support drug coverage decisions for all clinical and non-clinical criteria (financial business rules, pricing rules, etc.))

b) Compliance with all SCDHHS prior authorization rules, regulations, and policies

c) Notifications of decision to providers and Beneficiaries

d) Operation of a provider call center staffed with appropriate clinical personnel (meeting any state clinical licensure requirements, if applicable)

e) Assistance to SCDHHS, as needed, to support the appeal process

f) Detailed reporting and analysis on all aspects of the prior authorization program

a) Program eligibility

b) Existence of authorized prescribers

c) Existence of program coverage restrictions

d) Existence of alternative insurance (e.g., Medicare Part B or D, commercial coverage)

e) Other elements specified and approved by SCDHHS 138 Functional Prior Authorization Point of Sale The Contractor shall ensure that prior authorization requests containing insufficient information to render a final decision are identified with a status such as incomplete, on-hold, or pending.

a) All products identified as requiring prior authorization by SCDHHS

b) Developing web-based versions of criteria

c) Customized criteria must accommodate open-ended responses and allow the Contractor's clinical staff to review any necessary supporting documentation, such as faxed forms or letters of medical necessity, during the initial review of prior authorization request

d) Scripted protocols that may be used to approve prior authorization service requests 142 Functional Prior Authorization Point of Sale The Contractor shall provide a prior authorization system that must:

a) Be accessible to authorized users (i.e., designated staff)

b) Support prior authorization for a number of doses

c) Support prior authorization for period of time 143 Functional Prior Authorization Point of Sale The Contractor shall provide a prior authorization platform within the system that must maintain and allow the query of all pertinent information about prior authorization requests and determinations including, but not limited to, the following:

a) Requesting provider name b) Date and time of request c) Beneficiary identifiers d) Requested drug name, strength, form, and quantity e) Program eligibility of the beneficiary at the time of the determination f) Request status (i.e., approved, pended, denied) g) All reasons for denial or exception h) Prior authorization beginning and end dates i) Date and time of action on the request j) Comprehensive and flexible “free-text” notation functionality

a) Notifying prescribing providers and Beneficiaries of their appeal rights

b) Preparing the appropriate reports and documents to support the Contractor’s actions resulting in the request for an appeal

c) Appearing at hearings to defend a prior authorization denial decision

d) Providing the services of a clinician to engage in peer discussions with the SCDHHS Medical Director, or designee, and other SCDHHS clinical personnel to address an appeal related to pharmacy benefit services

e) Complying with the mandates and timelines stipulated by state and federal policies for response/resolution of any appeal

a) Implementation of the operational processes to support drug coverage decisions for all clinical and non-clinical criteria (financial business rules, pricing rules, etc.))

b) Compliance with all SCDHHS prior authorization rules, regulations, and policies

c) Notifications of decision to providers and Beneficiaries

d) Operation of a provider call center staffed with appropriate clinical personnel (meeting any state clinical licensure requirements, if applicable)

e) Assistance to SCDHHS, as needed, to support the appeal process

f) Detailed reporting and analysis on all aspects of the prior authorization program

a) Program eligibility

b) Existence of authorized prescribers

c) Existence of program coverage restrictions

d) Existence of alternative insurance (e.g., Medicare Part B, commercial coverage)

e) Other elements specified and approved by SCDHHS 172 Functional Prior Authorization Physician Administered Drug The Contractor shall ensure that prior authorization requests containing insufficient information to render a final decision are identified with a status such as incomplete, on-hold, or pending.

a) All products identified as requiring prior authorization by SCDHHS

b) Developing web-based versions of criteria

c) Customized criteria must accommodate open-ended responses and allow the Contractor's clinical staff to review any necessary supporting documentation, such as faxed forms or letters of medical necessity, during the initial review of prior authorization request

d) Scripted protocols that may be used to approve prior authorization service requests 176 Functional Prior Authorization Physician Administered Drug The Contractor shall provide a prior authorization system that must:

a) Be accessible to authorized users (i.e., designated staff)

b) Support prior authorization for a number of doses

c) Support prior authorization for period of time

d) Support prior authorization for new and existing drugs 177 Functional Prior Authorization Physician Administered Drug The Contractor shall provide a prior authorization platform within the system that must maintain and allow the query of all pertinent information about prior authorization requests and determinations including, but not limited to, the following:

a) Requesting provider name b) Date and time of request c) Beneficiary identifiers d) Requested drug name, strength, form, and quantity e) Program eligibility of the beneficiary at the time of the determination f) Request status (i.e., approved, pended, denied) g) All reasons for denial or exception h) Prior authorization beginning and end dates i) Date and time of action on the request j) Comprehensive and flexible “free-text” notation functionality

a) Notifying prescribing providers and Beneficiaries of their appeal rights

b) Preparing the appropriate reports and documents to support the Contractor’s actions resulting in the request for an appeal

c) Appearing at hearings to defend a prior authorization denial decision

d) Providing the services of a clinician to engage in peer discussions with the SCDHHS Medical Director, or designee, and other SCDHHS clinical personnel to address an appeal related to physician administered drugs

e) Complying with the mandates and timelines stipulated by state and federal policies for response/resolution of any appeal