Common use of Pharmacy Benefits Clause in Contracts

Pharmacy Benefits. Prescription drugs are a benefit under the HIP program to be covered by the Contractor. 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 PBM, the Contractor shall ensure compliance with all subcontracting requirements outlined in Section 2.7, including but not limited to EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK 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. The Contractor shall not be responsible for member pharmacy claims incurred prior to the effective date of this contract. The Contractor shall, at the direction of the Secretary, implement specified fee-for- service PDL and/or prior authorization, if unified PDL is not implemented. 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 ensure that at all times during the term of this contract its pharmacy benefit fully complies with applicable provisions of IC 12-15-35 and IC 12-15-35.5.

Pharmacy Benefits. Prescription drugs are a benefit under the HIP program to be covered by the Contractor. 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 PBM, the Contractor shall ensure compliance with all subcontracting requirements outlined in Section 2.7, including but not limited to EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK 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. The Contractor shall not be responsible for member pharmacy claims incurred prior to the effective date of this contract. The Contractor shall allow for FFS PBM claims processing for members in presumptive eligibility status until their plan eligibility and assignment are completed. The Contractor shall provide a proposal which considers a common or “unified” preferred drug list (PDL) for the pharmacy benefit. Unification of the PDL would include prior authorization (PA), step edit and utilization edit criteria. The Contractor shall, at the direction of the Secretary, implement specified fee-for- for-service PDL and/or prior authorization, if unified PDL is not implemented. 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, addition all claims (except emergency claims) from a non-IHCP prescribing provider providers will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre- 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 contractor shall ensure that at all times during the term of this contract its pharmacy benefit fully complies with applicable provisions of IC 12-15-35 and IC 12-15-35.5.