Drug Claims Sample Clauses

Drug Claims. Some drug claims are processed by a third-party Pharmacy Benefits Manager (PBM), while the Company processes claims for drugs covered under the Plan. The Plan Sponsor shall pay the Company an amount equal to the amount of the Plan Sponsor's maximum monthly and run-out liabilities for self-funded drug claims under the Plan. Such provision of money for drug claims is included in the Plan Sponsor's payments described in the Plan Sponsor's Payment Obligations Attachment. The drug claims are considered to include (i) charges for drugs, plus (ii) dispensing fees for prescriptions filled for Members by participating and mail-order pharmacies, and (iii) sales tax where required by law. Charges for drugs provided to Members may be based on the average wholesale price of a prescription drug as calculated by the PBM using a variety of factors, including but not limited to the First DataBank National Drug Data File or another nationally recognized pricing source. The PBM's method of calculating the average wholesale price of a prescription drug may change from time to time, as the PBM shall determine. The Company shall have no duty to notify the Plan Sponsor of any such change.

Drug Claims. The Client shall pay the Company the amounts that the Company bills for (i) Covered Drugs provided to Members during the preceding billing period, plus (ii) Dispensing Fees for such Covered Drugs during the preceding billing period, plus (iii) sales tax where required by law. For specific prescriptions for Covered Drugs, Company shall charge Client, net of any Member cost-share requirement payable for the prescription for the Covered Drug, the lesser of the Prescription Drug Charge or, as applicable, submitted U&C Charge for such Covered Drug. Company shall charge Client for Covered Drugs in accordance with the estimated Target Pricing terms set forth in the written proposal or similar document provided by Company to Client, which proposal or similar document is incorporated herein by reference. The “Target Pricing” means the aggregate, average Dispensing Fee target and aggregate, average AWP drug discount target(s) for covered drugs dispensed by Retail Pharmacies and Cigna Home Delivery Pharmacy that Company achieves during the then-current calendar year when measured with respect to aggregate utilization of covered drugs, including covered drugs for which enrollees’ cost-share payments are equal to some or all of the entire amount payable for the drug, under the subset of its group client book of business for which the applicable pricing suite is administered (the “Book of Business”). The Target Pricing assumes an estimated level and distribution of utilization across the relevant Book of Business of covered drugs in less than an 83-day supply and greater than or equal to 83 day supplies at Retail Pharmacies and Cigna Home Delivery Pharmacy, respectively. The Target Pricing includes (i) separate aggregate, average AWP drug discount targets for three drug categories: Brand Drugs, Generic Drugs, and Specialty Drugs dispensed by Retail Pharmacies and Cigna Home Delivery Pharmacy, and (ii) an aggregate, average Dispensing Fee target for Brand Drugs, Generic Drugs, and Specialty Drugs dispensed by Retail Pharmacies and Cigna Home Delivery Pharmacy. The average, aggregate drug discounts and average, aggregate Dispensing Fee that Client pays in a given calendar year with respect to its Plan utilization, which is not guaranteed to meet or exceed the Target Pricing, may vary from the Target Pricing due to a number of factors, such as, without limitation, the Client’s drug utilization patterns (e.g. which drugs Members utilize, the days’ supply of drugs utilized b...

Drug Claims. Claims for pharmacy services shall must meet the requirements listed in the NE-POP System user's manual. The same standards apply to non-NE-POP system claims.

Drug Claims. Effective for claims made on or after January 1, 2007: The Drug Plan will cover only the cost of generic drugs provided such are available. Coverage will be under the Enhanced Generic Substitution Option of Green Shield. Whenever a generic equivalent for a prescribed drug is available, reimbursement under the Drug Plan will be provided as follows: 1. When a prescription drug order or refill for a covered person has a generic equivalent (regardless of interchange ability), the maximum benefit under the plan for such drug will be limited to the cost of the lowest price generic drug, less the $5.00 deductible. 2. When the covered person chooses the more costly drug, in lieu of the lowest price generic, such person will be responsible for the difference in cost. 3. Subsections 1 and 2 are subject to the “adverse Drug Reaction” Letter located in the back of this chapter Over the Counter Drugs The Drug Plan will cover only the following over-the-counter (OTC) drugs; non-sedating antihistamines, antacids, enteric coated ASA, NSAID preparations, calcium therapy and, when medically necessary, laxatives. In addition, there will be a $300 per person per year maximum for OTC drugs. Coverage for weight loss drugs will be limited to one occurrence. The Conditional Drug Formulary date will be adjusted to January 1, 2009. All persons currently receiving, or who, within the 12 months prior to ratification, have received medications that become subject to a change in status as a result of this change will continue to be eligible for such medications without exceptions. The Drug Plan will reimburse to a maximum of $9.00 for a drug-dispensing fee. Any excess dispensing fee will be separate from the $5.00 deductible. Claim forms should be submitted directly to Green Shield Canada who will reimburse you for the cost of the lowest priced generic equivalent of all eligible drugs billed, less a deductible of $5.00 for each prescription issued. You will be reimbursed for the full cost of eligible drugs billed (less a $5.00 deductible), rather than the lowest priced generic equivalent cost, where there is no generic equivalent available. If you purchase your drugs through a participating Pharmacist who accepts a $5.00 deductible, all you have to do is to present your Identification Card with $5.00 per prescription and pay any costs in excess of the lowest priced generic equivalent, and the $9 dispensing fee cap, if necessary, and the Pharmacist will bill the carrier directly for the...