Section 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, den- tist, 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:

a.         The member will be out of the provider’s service area for an extended period of time and the prescrip- tion 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 covered prescription 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 pharmaceu- tical treatment to restore, improve, or maintain physical well being.

Historical Note

Adopted as an emergency effective May 20, 1982 pursu- ant 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 Octo-

ber 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 Sep- tember 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 September 6, 2014 (Supp. 14-3).