PHARMACY BENEFITS MANAGEMENT (PBM Sample Clauses

PHARMACY BENEFITS MANAGEMENT (PBM. 1. The ADMINISTRATION will monitor the Physical Health Program provided through the INSURER contracted in the Health Region/Area. This will be with sufficient specificity in order to provide for all Physical Health needs for all eligible beneficiaries residing within the municipalities comprising said area. 2. The INSURER will abide with the ADMINISTRATION’s guidelines for expediting access of beneficiaries to the Physical health Program and pharmacy benefits covered under the Health Reform Program. The ADMINISTRATION acknowledges that no modifications will be made to the PDL during the remaining contract period unless a previous cost impact analysis is conducted to evaluate any adverse, positive or cost-effective factors that could affect both parties’ interests which may impair contracted premiums rates. Notwithstanding any adverse and financial effect in a determination to address a modification, said determination by the ADMINISTRATION shall be subject to the identification, availability and approval of funds to subsidize the corresponding adjustment to be contemplated and as agreed with INSURER. 3. Concurrently with the terms of this contract, the INSURER agrees to work with the ADMINISTRATION’s Pharmacy Benefit Manager(s) as selected by the ADMINISTRATION. This will include cooperating with the selected PBM to electronically send on a daily basis eligibility file, physician file updates facilitate claims processing in a period specified, working with the selected PBM to specify, develop and implement the flow of information, utilization review deposit funds for the payment of claims to the pharmacy network according to the payments cycle specified by the PBM and customer service protocols, as well as, to cease billing and collection of rebates from drug manufacturers. 4. The ADMINISTRATION’s PBM, will provide the INSURER the services set forth in this Section as described hereto: Claims Processing and Administrative Services § Contracting and administration of the pharmacy network. The PBM will create a network of Participating Pharmacies, which will perform pharmacy services for Members at specified fees and discounts § Bi-monthly claim payments summary reports for each payment cycle § Notify each INSURER of the payment process, systems involved (NCPDP 2.0) and relevant time line. § Processing and mailing of pharmacy checks and remittance reports § Reconciliation of zero balance accounts § Generate list of participating pharmacies § Coordination of ...
Sample 1
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PHARMACY BENEFITS MANAGEMENT (PBM a. The MCO shall provide the County’s workers’ compensation pharmacy network through an exclusive agreement with a PBM Services provider who will dispense prescribed and authorized medications to the County’s injured workers in the most convenient and expedient method possible. The MCO shall enter into a Pharmacy Benefit Management Services Agreement (“PBM Agreement”) with a PBM Services provider of the County’s choosing. The terms of the PBM Agreement shall describe the obligations and responsibilities of the MCO and PBM (“Parties”), the PBM’s products, scope of services and fees as they apply exclusively to the County’s workers’ compensation claims. b. The MCO shall ensure that the PBM Services provider engages in pharmacy benefit management services, including, but not limited to, pharmacy network contracting, eligibility verification, pharmacy claims processing, Formulary and Prior Authorization administration, clinical and managed care services, and standard PBM customer services. These services collectively shall be known as "PBM Services". c. The MCO shall engage the County to assist with the PBM Services Plan Design, defining all aspects of the program, including but not limited to eligibility and verification process for walk- in and point of sale processing; Pharmacy adjudication parameters (e.g. formulary, drug utilization review edits, prior authorization, help desk support); network conversion; pharmacy card and communication materials; and billing and reporting parameters. d. The MCO shall ensure that the PBM Services include Electronic Data Integration (EDI) services at no charge and provide EDI feeds with the MCO’s Bill Review and TPA Claims Management systems. e. The MCO shall ensure that the PBM Services utilize the Division of Workers’ Compensation adopted evidence-based drug formulary, consistent with California’s Medical Treatment Utilization Schedule (MTUS)/ACOEM, to augment the provision of high-quality medical care, maximize health, and promote return to work in a timely fashion, while reducing administrative burden and cost. f. The MCO shall ensure that the PBM Services review all in-network and out-of-network pharmacy bills for reductions in pharmacy charges pursuant to the California OMFS. Also, discounts below the fee schedule as described in this Contract and the PBM Agreement shall apply whenever possible. g. The PBM Services shall focus on driving network penetration and managing drug utilization and cost through access to a ...
Sample 1

Related to PHARMACY BENEFITS MANAGEMENT (PBM

  • Medical Benefits The Company shall reimburse the Employee for the cost of the Employee's group health, vision and dental plan coverage in effect until the end of the Termination Period. The Employee may use this payment, as well as any other payment made under this Section 6, for such continuation coverage or for any other purpose. To the extent the Employee pays the cost of such coverage, and the cost of such coverage is not deductible as a medical expense by the Employee, the Company shall "gross-up" the amount of such reimbursement for all taxes payable by the Employee on the amount of such reimbursement and the amount of such gross-up.

  • Health Care Savings Plan As provided in this Agreement, eligible ASF Members will participate in the health care savings plan (HCSP) established under Minnesota Statute 352.98, and as administered by the Plan Administrator. The Employer is responsible only for transferring funds, as specified in this agreement, to the Plan Administrator. Subd. 1. All ASF Members who receive severance pay as defined in Section A of this article must participate in the health care savings plan. Subd. 2. All severance pay as defined in Section B of this article shall be transferred to the severed employee's health care savings plan account. At the time of separation, if an ASF Member has an approved exception to participation in the health care savings plan account from the plan administrator, then the ASF Member shall receive this payment in one lump sum payment of cash.

  • Retiree Medical Benefits If Executive is or would become fifty-five (55) or older and Executive's age and service equal sixty-five (65) and Executive has at least five (5) years of service with the Company within two (2) years of Change in Control, Executive is eligible for retiree medical benefits (as such are determined immediately prior to Change in Control). Executive is eligible to commence receiving such retiree medical benefits based on the terms and conditions of the applicable plans in effect immediately prior to the Change in Control.

  • Financial Services Compensation Scheme We are a participant in the Financial Services Compensation Scheme (the “FSCS”). As a retail client you may be eligible to claim compensation from the FSCS in certain circumstances if we, any approved bank, our nominee company or eligible custodian are in default. Most types of investment business are covered in full for the first £85,000 of any eligible claim. Not every investor is eligible to claim under this scheme: for further information please contact us, or the FSCS directly at xxx.xxxx.xxx.xx.

  • Standard Company Benefits Executive shall be entitled to participate in all employee benefit programs for which Executive is eligible under the terms and conditions of the benefit plans that may be in effect from time to time and provided by the Company to its employees. The Company reserves the right to cancel or change the benefit plans or programs it offers to its employees at any time.

  • Health Benefits For the eighteen (18) month period following the Termination Date, provided that Executive is eligible for, and timely elects COBRA continuation coverage, the Company will pay on Executive’s behalf, the monthly cost of COBRA continuation coverage under the Company’s group health plan for Executive and, where applicable, her spouse and dependents, at the level in effect as of the Termination Date, adjusted for any increase in such level paid by the Company for active employees, less the employee portion of the applicable premiums that Executive would have paid had she remained employed during the such eighteen (18) month period (the COBRA continuation coverage period shall run concurrently with the eighteen (18) month period that COBRA premium payments are made on Executive’s behalf under this subsection 1(a)(ii)). The reimbursements described herein shall be paid in monthly installments, commencing on the sixtieth (60th) day following the Termination Date, provided that the first such installment payment shall include any unpaid reimbursements that would have been made during the first sixty (60) days following the Termination Date. Notwithstanding the foregoing, the Company’s payment of the monthly COBRA premiums in accordance with this subsection 1(a)(ii) shall cease immediately upon the earlier of: (A) the end of the eighteen (18) month period following the Termination Date, or (B) the date that Executive is eligible for comparable coverage with a subsequent employer. Executive agrees to notify the Company in writing immediately if subsequent employment is accepted prior to the end of the eighteen (18) month period following the Termination Date and Executive agrees to repay to the Company any COBRA premium amount paid on Executive’s behalf during such period for any period of employment during which group health coverage is available through a subsequent employer. Notwithstanding the foregoing, the Company reserves the right to restructure the foregoing COBRA premium payment arrangement in any manner necessary or appropriate to avoid fines, penalties or negative tax consequences to the Company or Executive (including, without limitation, to avoid any penalty imposed for violation of the nondiscrimination requirements under the Patient Protection and Affordable Care Act or the guidance issued thereunder), as determined by the Company in its sole and absolute discretion.

  • Developer Compensation for Emergency Services If, during an Emergency State, the Developer provides services at the request or direction of the NYISO or Connecting Transmission Owner, the Developer will be compensated for such services in accordance with the NYISO Services Tariff.

  • Retiree Health Benefits 1. There is currently in effect a retiree health benefit program for retired members of LACERS under LAAC Division 4, Chapter 11. All covered employees who are members of LACERS, regardless of retirement tier, shall contribute to LACERS four percent (4%) of their pre-tax compensation earnable toward vested retiree health benefits as provided by this program. The retiree health benefit available under this program is a vested benefit for all covered employees who make this contribution, including employees enrolled in LACERS Tier 3. 2. With regard to LACERS Tier 1, as provided by LAAC Section 4.1111, the monthly Maximum Medical Plan Premium Subsidy, which represents the Kaiser 2-party non-Medicare Part A and Part B premium, is vested for all members who made the additional contributions authorized by LAAC Section 4.1003(c). 3. Additionally, with regard to Tier 1 members who made the additional contribution authorized by LAAC Section 4.1003(c), the maximum amount of the annual increase authorized in LAAC Section 4.1111(b) is a vested benefit that shall be granted by the LACERS Board. 4. With regard to LACERS Tier 3, the Implementing Ordinance shall provide that all Tier 3 members shall contribute to LACERS four percent (4%) of their pre-tax compensation earnable toward vested retiree health benefits, and shall amend LAAC Division 4, Chapter 11 to provide the same vested benefits to all Tier 3 members as currently are provided to Tier 1 members who make the same four percent (4%) contribution to LACERS under the retiree health benefit program. 5. The entitlement to retiree health benefits under this provision shall be subject to the rules under LAAC Division 4, Chapter 11 in effect as of the effective date of this provision, and the rules that shall be placed into LAAC Division 4, Chapters 10 and 11, with regard to Tier 3, by the Implementing Ordinance. 6. As further provided herein, the amount of employee contributions is subject to bargaining in future MOU negotiations. 7. The vesting schedule for the Maximum Medical Plan Premium Subsidy for employees enrolled in LACERS Tier 1 and LACERS Tier 3 shall be the same. 8. Employees whose Health Service Credit, as defined in LAAC Division 4, Chapter 11, is based on periods of part-time and less than full-time employment, shall receive full, rather than prorated, Health Service Credit for periods of service. The monthly retiree medical subsidy amount to which these employees are entitled shall be prorated based on the extent to which their service credit is prorated due to their less than full time status.

  • Educational Benefits The Employer agrees to provide educational benefits to employees that are in permanent status as of the first day of the quarter they are registering in accordance with the Employer’s space-available tuition waiver policy and employee 50% operating fee tuition waiver policy, to include:

  • Incentive, Savings and Retirement Plans During the Employment Period, the Executive shall be entitled to participate in all incentive, savings and retirement plans, practices, policies and programs applicable generally to other peer executives of the Company and its affiliated companies, but in no event shall such plans, practices, policies and programs provide the Executive with incentive opportunities (measured with respect to both regular and special incentive opportunities, to the extent, if any, that such distinction is applicable), savings opportunities and retirement benefit opportunities, in each case, less favorable, in the aggregate, than the most favorable of those provided by the Company and its affiliated companies for the Executive under such plans, practices, policies and programs as in effect at any time during the 120-day period immediately preceding the Effective Date or if more favorable to the Executive, those provided generally at any time after the Effective Date to other peer executives of the Company and its affiliated companies.

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