Pharmacy Benefits Manager Sample Clauses

Pharmacy Benefits Manager. The pharmacy benefits available to You under this Contract are managed by Our Pharmacy Benefits Manager (PBM). The PBM is a pharmacy benefits management company with which We contract to manage Your pharmacy benefits. The PBM has a nationwide network of retail pharmacies, a Mail Service pharmacy, and provides clinical management services. The management and other services the PBM provides include, among others, making recommendations to, and updating, the Covered Prescription Drug list (also known as a Formulary) and managing a network of retail pharmacies and, operating a Mail Service pharmacy. The PBM, in consultation with Us, also provides services to promote and enforce the appropriate use of pharmacy benefits, such as review for possible excessive use, recognized and recommended dosage regimens, Drug interactions or Drug/pregnancy concerns. You may request a copy of the Covered Prescription Drug list by calling the Customer Service telephone number on the back of Your I.D. Card. The Covered Prescription Drug list is subject to periodic review and amendment. Inclusion of a Drug or related item on the Covered Prescription Drug list is not a guarantee of Coverage. You may request a list of Pharmacies in the PBM network by calling the customer service number listed on the back of Your I.D. Card. Prescription Drugs, unless otherwise stated below, must be Medically Necessary and not Experimental/Investigative, in order to be Covered Health Services. For certain Prescription Drugs, the prescribing Physician may be asked to provide additional information before the PBM and/or the Contract can determine Medical Necessity. The Contract may, in its sole discretion, establish quantity and/or age limits for specific Prescription Drugs which the PBM will administer. Covered Health Services will be limited based on Medical Necessity, quantity and/or age limits established by the Contract, or utilization guidelines. Prior Authorization may be required for certain Prescription Drugs (or the prescribed quantity of a particular Drug). Prior Authorization helps promote appropriate utilization and enforcement of guidelines for Prescription Drug benefit Coverage. At the time You fill a prescription, the Participating Pharmacist is informed of the Prior Authorization requirement through the pharmacy’s computer system. The PBM uses pre-approved criteria, developed by Our Pharmacy and Therapeutics Committee which is reviewed and adopted by Us. We, or the PBM may contact Your ...

Pharmacy Benefits Manager. (PBM) means the organization that manages the medication benefits that are given to Clients that qualify for medication benefits.