Drug Coverage. Prescription drugs and certain over-the-counter drugs are benefits under the Hoosier Care Connect program to be covered by the Contractor. Members are responsible for a copayment for covered drugs in the amount outlined in Section 12.2. The Contractor shall support FSSA in promptly responding to public and legislative inquiries involving the design and management of the Contractor’s pharmacy benefit. If the Contractor elects to subcontract with a pharmacy benefit manager (PBM), the Contractor must ensure compliance with all subcontracting requirements outlined in Section 2.3, including but not limited to conducting regular audits and monitoring of the subcontractor’s data and performance, as well as requiring their PBM to conduct regular audits of their pharmacy provider networks.
Drug Coverage. Prescription drugs, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Healthwise program to be covered by the Contractor. Per 21 § CFR 203.3, prescription drug means any drug (including any biological product, except for blood and blood components intended for transfusion or biological products that are also medical devices) required by Federal law (including Federal regulation) to be dispensed only by a prescription, including finished dosage forms and bulk drug substances subject to section 503(b) of the Social Security Act. The Contractor agrees to abide by 42 CFR 438.3(s), the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) and P.L. 115-271, “SUPPORT” Act. The Contractor shall follow the statewide unified preferred drug list (SUPDL) for the pharmacy benefit. The SUPDL will consist of the fee-for-service (FFS) PDL. Adoption of the SUPDL shall include alignment of prior authorization (PA), forms, and step edit and utilization edit criteria for drugs and drug classes that are part of the SUPDL. The Contractor will discontinue and not seek commercial discounts and commercial rebate agreements with pharmaceutical manufacturers for IHCP member pharmacy benefits. The Contractor may only set a Maximum Allowable Cost (MAC) rate on a multiple source drug available from at least two manufacturers. The MAC rate may not be applied when the brand product is preferred over available generics on the SUPDL. The Contractor shall develop an escalation process for specified unique review processes and requests submitted by State or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall always ensure that, during the term of this contract, its pharmacy benefit fully complies with applicable provisions of law including IC 12-15-35, IC 12-15-35.5 and IC 27-1-24.5. If the Contractor enters into a contract or agreement with a Pharmacy Benefit M...
Drug Coverage. The Company will increase the life time maximum from ten thousand ($10,000.00) dollars to one hundred twenty thousand ($120,000.00) dollars for hospital, extended health and drug benefits for full-time employees.
Drug Coverage. Prescription drugs, certain over-the-counter drugs, and pharmacy supplements are benefits under the Hoosier Care Connect program to be covered by the Contractor. The Contractor agrees to abide by 42 CFR 437-438.3(s), the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) and P.L. 115-271, “SUPPORT” Act. If directed as such by FSSA, the Contractor shall utilize a common or unified PDL/PA criteria, including discontinuation of commercial discount and commercial rebates agreements with pharmaceutical manufacturers for IHCP member pharmacy benefits, or consolidation of the pharmacy benefit under the FFS program. If the Contractor enters into a contract or agreement with a Pharmacy Benefit Manager (PBM) for the provision and administration of pharmacy services, the contract or agreement shall be developed as a pass-through pricing model as defined below:
Drug Coverage. Prescription drugs, certain over-the-counter drugs, and pharmacy supplements are benefits under the Hoosier Healthwise program to be covered by the Contractor. The Contractor agrees to abide by 42 CFR 437-438.3(s), the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) and P.L. 115-271, “SUPPORT” Act. If directed as such by FSSA, the Contractor shall utilize common or unified PDL/PA criteria, including discontinuation of commercial discount and commercial rebate agreements with pharmaceutical manufacturers for IHCP member pharmacy benefits, or consolidation of the pharmacy benefit under the FFS program. The Contractor shall assure proper and complete PBM agent training. The Contractor shall always ensure that, during the term of this contract, its pharmacy benefit fully complies with applicable provisions of law including IC 12-15-35, IC 12-15-35.5 and IC 27-1-24.5. If the Contractor enters into a contract or agreement with a Pharmacy Benefit Manager (PBM) for the provision and administration of pharmacy services, the contract or agreement shall be developed as a pass-through pricing model as defined below:
Drug Coverage. Prescription drugs, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the HIP program to be covered by the Contractor. Per 21 § CFR 203.3, prescription drug means any drug (including any biological product, except for blood and blood components intended for transfusion or biological products that are also medical devices) required by Federal law (including Federal regulation) to be dispensed only by a prescription, including finished dosage forms and bulk drug substances subject to section 503(b) of the Social Security Act. The Contractor agrees to abide by 42 CFR 438.3(s), the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) and P.L. 115-271, “SUPPORT” Act. The Contractor shall follow the statewide unified preferred drug list (SUPDL) for the pharmacy benefit. The SUPDL will consist of the fee-for-service (FFS) PDL. Adoption of the SUPDL shall include alignment of prior authorization (PA), forms, and step edit and utilization edit criteria for drugs and drug classes that are part of the SUPDL. The Contractor will discontinue and not seek commercial discounts and commercial rebate agreements with pharmaceutical EXHIBIT 1.A SCOPE OF WORK manufacturers for IHCP member pharmacy benefits. The Contractor may only set a Maximum Allowable Cost (MAC) rate on a multiple source drug available from at least two manufacturers. The MAC rate may not be applied when the brand product is preferred over available generics on the SUPDL. The Contractor shall assure proper and complete PBM agent training.
Drug Coverage. Prescription drugs, certain over-the-counter drugs, and pharmacy supplements are benefits under the HIP program to be covered by the Contractor. The Contractor agrees to abide by 42 CFR 437-438.3(s), the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) and P.L. 115-271, “SUPPORT” Act. If directed as such by FSSA, the Contractor shall utilize common or unified PDL/PA criteria, including discontinuation of commercial discount and commercial rebate agreements with pharmaceutical manufacturers for IHCP member pharmacy benefits, or consolidation of the pharmacy benefit under the FFS program. The Contractor shall assure proper and complete PBM agent training. The Contractor shall always ensure that, during the term of this contract, its pharmacy benefit fully complies with applicable provisions of law including IC 12-15-35, IC 12-15-35.5 and IC 27-1- 24.5. If the Contractor enters into a contract or agreement with a Pharmacy Benefit Manager (PBM) for the provision and administration of pharmacy services, the contract or agreement shall be developed as a pass-through pricing model as defined below: All monies related to services provided for the Contractor are passed through to the Contractor, including but not limited to dispensing fees and ingredient costs paid to pharmacies, and all revenue received, including but not limited to pricing discounts paid to the PBM, rebates (including manufacturer fees and administration fees for rebating), inflationary payments, and supplemental or commercial rebates; All payment streams, including any financial benefits such as rebates, discounts, credits, clawbacks, fees, grants, reimbursements, or other payments that the PBM receives related to services provided for the Contractor are fully disclosed to the Contractor, and provided to the State upon request, and; EXHIBIT 1 SCOPE OF WORK – HEALTHY INDIANA PLAN The PBM is paid an administrative fee which covers the cost of providing the PBM services as described in the PBM contract or agreement as well as margin. The payment model for the PBM’s administrative fee shall be made available to the State. If concerns are identified, the State reserves the right to request any changes be made to the payment model.
Drug Coverage. Prescription drugs, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the HIP program to be covered by the Contractor. Per 21 § CFR 203.3, prescription drug means any drug (including any biological product, except for blood and blood components intended for transfusion or biological products that are also medical devices) required by Federal law (including Federal regulation) to be dispensed only by a prescription, including finished dosage forms and bulk drug substances subject to section 503(b) of the Social Security Act. The Contractor agrees to abide by 42 CFR 438.3(s), the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) and P.L. 115-271, “SUPPORT” Act. The Contractor shall follow the statewide unified preferred drug list (SUPDL) for the pharmacy benefit. The SUPDL will consist of the fee-for-service (FFS) PDL. Adoption of the SUPDL shall include alignment of prior authorization (PA), forms, and step edit and utilization edit criteria for drugs and drug classes that are part of the SUPDL. The Contractor will discontinue and not seek commercial discounts and commercial rebate agreements with pharmaceutical EXHIBIT 1.A
Drug Coverage. Integrated with the Ontario Drug Plan with the ODP first (1st) payment.
Drug Coverage. Effective June 1, 2017 the employer will provide each member with a drug card for direct billing of covered drugs. The employer advises that this new coverage is for generic drugs, unless the prescribing physician specifies a name brand.
