2.2.1 Pharmacy Network The CONTRACTOR shall maintain a robust pharmacy network to ensure that all HDAP-enrolled patients have adequate access to HDAP formulary medications. 2.2.1.1 The pharmacy network shall include sufficient options to allow each HDAP-enrolled patient with insurance coverage, regardless of insurance type, to access the patient's insurance benefit, so as to ensure that HDAP payment is secondary to available insurance. The pharmacy network shall include retail, specialty, and mail-order pharmacies, including one or more pharmacies: serving each geographic area of the state. in the pharmacy network of each of the following insurers offering.prescription drug coverage in Hawaii: HMSA, UHA, and HMAAKaiser Permanente is a significant provider of HIV care in the state, providing Quest, Medicare, group and individual insurance plans. TheCONTRACTOR shall include Kaiser Permanente in the HDAP pharmacynetwork. Pursuant to §431R-2, HRS, the CONTRACTOR shall maintain an openenrollment process that will allow additional pharmacies to enter thenetwork. 2.2.2 Electronic Claims Processing 2.2.2.1 The CONTRACTOR shall provide for online claims adjudication and ensure pointof-sale split billing to primary and secondary payers. The CONTRACTOR shall maintain a unique RxBIN/PCN combination for HDAP and shall comply with NCPDP standards for pharmacy drug claims and coordination of benefits. 2.2.3 Primary and Secondary Payer Coordination The CONTRACTOR shall provide for the coordination of primary and secondary payers of prescription claims. The CONTRACTOR shall have the ability to transmit primary and secondary insurance information to pharmacies. 2.2.3.1 For Clients with insurance coverage for medications, the CONTRACTOR shall bill HDAP secondary to insurance for eligible dispenses of HDAP formulary medications. The CONTRACTOR shall bill to HDAP an amount equal to the Client's cost share as determined by the Client's primary insurance benefit. The Client's cost share shall include deductible, co pay and coinsurance amounts, as well as any full costs when a dispensed HDAP formulary medication, or more than one, falls within Medicare coverage gaps. 2.2.3.2 For insured Clients whose insurance denies coverage for an HDAP formulary medication, the CONTRACTOR shall obtain HDAP approval to bill HDAP as primary as specified in Rate Schedule (Exhibit "A"). 2.2.3.3 For Clients without insurance coverage for medications, the CONTRACTOR shall bill HDAP as the primary payer as specified in Rate Schedule (Exhibit "A").
