{"data":{"id":"us-ky/krs-304.17a-535","jurisdiction":"us-ky","citation":"KRS 304.17A-535","heading":"Drug utilization waiver program -- Limitations on generic","body":"substitution -- Application to drug formulary.\n(1) A managed care plan shall include a drug utilization review program, the primary\nemphasis of which shall be to enhance quality of  care for enrollees by assuring\nappropriate drug therapy within the health care provider's legally authorized scope\nof practice, that:\n(a) Includes the following:\n1. Retrospective review of prescription drugs furnished to enrollees;\n2. Education of health care providers and enrollees regarding the\nappropriate use of prescription drugs; and\n3. Ongoing periodic examination of data on outpatient prescription drugs\nto ensure quality therapeutic outcomes for enrollees; and\n(b) Complies with KRS 304.17A-163 and 304.17A-1631.\n(2) The drug utilization review program shall utilize the following to effectuate the\npurposes of subsection (1) of this section:\n(a) Relevant clinical criteria and standards for drug therapy;\n(b) Nonproprietary criteria and standards developed and revised through input\nfrom participating health care providers;\n(c) Intervention that focuses on improving therapeutic outcomes; and\n(d) Measures to ensure the confidentiality of the relationship between an enrollee\nand a health care provider.\n(3) When, in the professional opinion of a provider with prescriptive authority, the\nprovider determines that generic substitution of a pharmaceutical product is\nmedically inappropriate, the provider shall prescribe the pharmaceutical product the\nprovider determines medically appropriate with the indication \"Do Not Substitute,\"\nand no substitution shall be made without the provider's approval.\n(4) A managed care plan that restricts pharmacy benefits to a drug formular y shall have\nan exceptions policy through which the managed care plan may cover a prescription\ndrug not included on the formulary.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=53229","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"f210c95a2b1ccacb7baa0362c5196d338aea1dfd2cbfce67b44fa0d9fba12c70","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-533","next":"us-ky/krs-304.17a-540"},"notice":"GroundRules: Original legal text. Not legal advice."}