Common use of Carve-Out of Select Drugs Clause in Contracts

Carve-Out of Select Drugs. The drugs described in this section are excluded from the Contractor’s capitation rate; these are referred to as “carved-out” drugs. The State’s fiscal agent pays claims for carved-out drugs on a fee-for-service basis for the Contractor’s members. While these drugs are not the financial responsibility of the Contractor, the Contractor shall ensure coordination of all Medicaid covered drugs and implement strategies to prevent duplication and fragmentation of care across the healthcare delivery system. Select drugs are carved out of the Hoosier Healthwise capitation rates for CY 2018 (full rating period). Below is a list of the drugs that have been carved out: ▪ Hepatitis C drugs (identified by a GPI-6 of 125350 or 123599) ▪ Spinraza ▪ Exondys 51 ▪ Kymriah ▪ Yescarta ▪ Luxturna ▪ Hemlibra ▪ Vertex cystic fibrosis drugs, including Orkambi, Kalydeco, and Symdeko Effective May 1, 2018 the state is also carving out hemophilia drugs with drug class ID of 8510 and those drugs with a Generic product indicator (GPI) beginning with 8510.

Carve-Out of Select Drugs. The drugs described in this section are excluded from the Contractor’s capitation rate; these are referred to as “carved-out” drugs. The State’s fiscal agent pays claims for carved-out drugs on a fee-for-service basis for the Contractor’s members. While these drugs are not the financial responsibility of the Contractor, the Contractor shall ensure coordination of all Medicaid covered drugs and implement strategies to prevent duplication and fragmentation of care across the healthcare delivery system. Select drugs are carved out of the Hoosier Healthwise Care Connect capitation rates for CY 2018 (full rating period). Below is a list of the drugs that have been carved out: ▪  Hepatitis C drugs (identified by a GPI-6 of 125350 or 123599) ▪  Spinraza ▪  Exondys 51 ▪  Kymriah ▪  Yescarta ▪  Luxturna ▪  Hemlibra ▪  Vertex cystic fibrosis drugs, including Orkambi, Kalydeco, and Symdeko Effective May 1, 2018 the state is also carving out hemophilia drugs with drug class ID of 8510 and those drugs with a Generic product indicator (GPI) beginning with 8510.