Ariz. Admin. Code § R9-22-209 - Pharmaceutical Services

A.An inpatient or outpatient provider, including a hospital, clinic, other appropriately licensed health care facility, and pharmacy may provide covered pharmaceutical services.

B.The Administration or a contractor shall require a provider to make pharmaceutical services:

1. Available during customary business hours, and

2. Located within reasonable travel distance of a member's residence.

C.Pharmaceutical services are covered if:

1. Prescribed for a member by the member's primary care provider, attending physician, practitioner, or dentist;

2. Prescribed by a specialist upon referral from the primary care provider or attending physician; or

3. The contractor or its designee authorizes the service.

D.The following limitations apply to pharmaceutical services:

1. A medication personally dispensed by a physician, dentist, or a practitioner within the individual's scope of practice is not covered, except in geographically remote areas where there is no participating pharmacy or if accessible pharmacies are closed.

2. A new prescription or refill in excess of a 30 day supply is not covered unless:

3. A prescription or refill in excess of a 30-day supply is covered if:

a. The medication is prescribed for chronic illness and the prescription is limited to no more than a 100-day supply or 100-unit doses, whichever is greater.

b. a. The member will be out of the provider's service area for an extended period of time and the prescription is limited to the extended time period, not to exceed a 90 day supply.; or

b. The Contractor authorizes the prescription for an extended time period not to exceed a 90-day supply.

3. An over-the-counter medication, in place of a coveredprescription medication, is covered only if the over-the-counter medication is appropriate, equally effective, safe,and less costly than the covered prescription medication.

E. A contractor shall monitor and ensure sufficient services to prevent any gap in the pharmaceutical regimen of a member who requires a continuing or complex regimen of pharmaceutical treatment to restore, improve, or maintain physical well being.

Notes

Ariz. Admin. Code § R9-22-209

Adopted as an emergency effective May 20, 1982 pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-3). Former Section R9-22-209 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Amended effective October 1, 1985 (Supp. 85-5). Amended effective September 24, 1986 (Supp. 86-5). Amended subsections (A) and (C) effective December 22, 1987 (Supp. 87-4). Amended subsection (C)(3), effective May 30, 1989 (Supp. 89-2). Amended under an exemption from the Administrative Procedure Act effective March 22, 1993; received in the Office of the Secretary of State March 24, 1993 (Supp. 93-1). Amended effective December 13, 1993 (Supp. 93-4). Section repealed, new Section adopted effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 20 A.A.R. 1949, effective 9/6/2014.