Common use of Drug Coverage Clause in Contracts

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: 1. 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; 2. 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; 3. 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, and pharmacy supplements are benefits under the Hoosier Care Connect 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 a common or unified PDL/PA criteria, including discontinuation of commercial discount and commercial rebates 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: 1. : All monies related to services provided for the Contractor are passed through to the Contractor, including but not limited to: 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; 2. ; 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; 3. ; 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, 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: 1. 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; 2. 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; 3. 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 StateSt ate. 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, and pharmacy supplements are benefits under the Hoosier Care Connect 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 a common or unified PDL/PA criteria, including discontinuation of commercial discount and commercial rebates 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: 1. All monies related to services provided for the Contractor are passed through to the Contractor, including but not limited to: 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; 2. 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; 3. 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 t o the payment model.

Drug Coverage. Prescription drugs, certain over-the-counter drugs, and pharmacy supplements are benefits under the Hoosier Care Connect 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 a common or unified PDL/PA criteria, including discontinuation of commercial discount and commercial rebates 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: 1. All monies related to services provided for the Contractor are passed through to the Contractor, including but not limited to: 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; 2. 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; 3. 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, and pharmacy supplements are benefits under the Hoosier Care Connect 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 a common or unified PDL/PA criteria, including discontinuation of commercial discount and commercial rebates 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: 1. : All monies related to services provided for the Contractor are passed through to the Contractor, including but not limited to: 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; 2. ; 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; 3. ; 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. 3.4.1 Drug Rebates The Contractor shall ensure compliance with the requirements under Section 1927 of the Social Security Act. In accordance with the Affordable Care Act, manufacturers that participate in the Medicaid drug rebate program are required to pay rebates for drugs dispensed to individuals enrolled with a Medicaid Managed Care Entity. To facilitate collection of these rebates, FSSA must include utilization data of HIP contractors when generating quarterly drug rebate invoices to manufacturers as well as reporting quarterly utilization statistics to the Centers for Medicare and Medicaid Services (CMS). The Contractor shall provide reports to the State to support rebate collection per 42 CFR 438.3(s)(2) and section 1927(b)(1)(A) of the Social Security Act. This reporting shall include physician-administered drugs. The State intends to use and share the Contractor paid amount information on the State’s pharmacy claims extracts for rebate purposes. The Contractor shall provide this reporting to the State in the manner and timeframe prescribed by FSSA, including, but not limited to, through the submission of complete and accurate pharmacy encounter data and a rebate file to the State or its designee. An example of a rebate file is provided in the Bidders’ Library; this file layout is provided as an example only and is subject to change. Throughout the course of the Contract, FSSA may update the file layout to support rebate collection. FSSA shall make its best effort to provide the Contractor sixty (60) days advanced notice of the change and the Contractor shall be required to comply with the change in the timeframe designated by the State. The Contractor shall comply with all file layout requirements including, but not limited to, format and naming conventions and submission of paid amounts. Failure to comply with the drug rebate reporting requirements established by FSSA will subject the Contractor to the remedies outlined in Contract Exhibit 2 Contract Compliance and Pay for Outcomes. Requirements for pharmacy encounter claims are outlined in Section 8.6. Additionally, the Contractor shall assist FSSA or the State’s PBM contractor in resolving drug rebate disputes with a manufacturer, at Contractor’s expense. As maximization of drug rebates is heavily dependent on cooperation by the Contractor with the State or the State’s designated rebate vendor, the Contractor must respond to all inquiries from the State or the vendor pertaining to all drug rebate matters in a timely fashion. The Contractor must acknowledge receipt of such inquiries in writing (e.g., by e- mail) within two (2) business days of receipt, and in that acknowledgement provide a best estimate of when a final response will be provided.

Drug Coverage. Prescription drugs, certain over-the-counter drugs, and pharmacy supplements are benefits under the Hoosier Care Connect 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 a common or unified PDL/PA criteria, including discontinuation of commercial discount and commercial rebates 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: 1. All monies related to services provided for the Contractor are passed through to the Contractor, including but not limited to: 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; 2. 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; 3. 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.