Common use of Pharmacy Benefits Clause in Contracts

Pharmacy Benefits. a. Pharmacy benefits are available to all State of Ohio employees and their dependents enrolled in a health plan. Pharmacy benefits may be provided by the individual health plan or upon the recommendation of the JHCC, the Director of DAS may carve-out pharmacy benefits from the health plans. b. The JHCC will review the procedure for obtaining biotech drugs and upon recommendation of the JHCC, the Director of DAS may require that such biotech drugs be obtained from specialty pharmacies. Furthermore, upon recommendation from the JHCC, the Director of DAS may establish a separate cost-sharing structure for biotech or lifestyle drugs. c. After consultation with the JHCC the Director of DAS may implement the following: (1) Alternative pharmacy cost-sharing plan options such as co-insurance. (2) Coverage of certain Over-the-Counter (OTC) drugs. (3) Alternative pharmacy procurement and distribution channels. d. No health plan may remove from its formulary or require preauthorization for any prescription drug that is among its ten most frequently prescribed drugs unless the health plan has notified the Employer and consulted with the JHCC, including in that consultation a review of the health plan research recommending that the drug be excluded or put on preauthorization status. e. Retail pharmacy program. There will be a program for short- term (up to thirty (30) days) prescriptions, with easy access to pharmacies throughout the state. Commencing July 1, 2006, co-pays for a thirty (30) day supply of prescription drugs including coverage of prescriptions from a licensed dentist are: $10 co-payment for generic, twenty dollar ($20) co-pay for a formulary brand name drug, and a forty dollar ($40) co- pay for a non-formulary brand name drug. Where a generic equivalent is available, the co-pay for a non-formulary brand name drug shall be forty dollar ($40) and the difference in cost between the generic equivalent and the non-formulary brand name drug. Commencing July 1, 2007 the following drug co- pays shall apply. Co-pays for a thirty (30) day supply of prescription drugs including coverage of prescriptions from a licensed dentist are: ten dollar ($10) co-payment for generic, twenty-two dollar ($22) co-pay for a formulary brand name drug, and a forty-four dollar ($44) co-pay for a non-formulary brand name drug. Where a generic equivalent is available, the co-pay for a non-formulary brand name drug shall be forty- four dollar ($44) and the difference in cost between the generic equivalent and the non-formulary brand name drug. Commencing July 1, 2008, the following drug co-pays shall apply. Co-pays for a thirty (30) day supply of prescription drugs including coverage of prescriptions from a licensed dentist are: $10 co-payment for generic, twenty-five dollar ($25) co-pay for a formulary brand name drug and a fifty dollar ($50) co-pay for a non-formulary brand name drug. Where a generic equivalent is available, the co-pay for a non- formulary brand name drug shall be fifty dollar ($50) and the difference in cost between the generic equivalent and the non- formulary brand name drug. f. Mail Order Drug Program When a prescription for long-term or maintenance medications lasting more than thirty (30) days is necessary, persons enrolled in Ohio Med must use the mail order program for long-term maintenance drugs after the second prescription fill at retail. From July 1, 2006 through June 30, 2007, the following co-pays for mail order prescriptions of ninety (90) days shall apply. For a generic drug the co-pay is twenty-five dollars ($25). The co-pay is fifty dollars ($50) for a formulary brand name drug, and one hundred dollars ($100) for a non- formulary brand name drug. Where a generic equivalent is available, the co-pay for a non-formulary brand name drug is one hundred dollars $100 and the difference in cost between the generic equivalent and the non-formulary brand name drug. Commencing July 1, 2007, the following co-pays for mail order prescriptions of ninety (90) days shall apply. For a generic drug the co-pay is twenty-five dollars ($25). The co- pay is fifty-five dollars ($55) for a formulary brand name drug, and one hundred ten dollars ($110) for a non-formulary brand name drug. Where a generic equivalent is available, the co-pay for a non-formulary brand name drug is one hundred ten dollars ($110) and the difference in cost between the generic equivalent and the non-formulary brand name drug. Commencing July 1, 2008 the following co-pays for mail order prescriptions of ninety (90) days shall apply. For a generic drug the co-pay is twenty-five dollars ($25). For a formulary brand name drug the co-pay is sixty-two dollars and fifty cents ($62.50). For a non-formulary brand name drug the co-pay is one hundred twenty-five dollars ($125). Where a generic equivalent is available the co-pay for a non-formulary brand name drug shall be one hundred twenty-five dollars ($125) and the difference in cost between the generic equivalent and the non-formulary brand name drug. g. Prior Authorizations and Exclusions for Prescription Drug Programs (1) Prior Authorization. A number of prescription drugs require prior authorization, all approvals for such prescriptions will be handled by the Pharmacy Benefit Manager (PBM). During the life of this contract other drugs may be added to the list of prior authorization after consultation with the JHCC, if required. (2) It is recognized that certain drugs may not be covered by the plans.

Pharmacy Benefits. a. Pharmacy benefits are available to all State of Ohio employees and their dependents enrolled in a health plan. Pharmacy benefits may be provided by the individual health plan or upon the recommendation of the JHCC, the Director of DAS may carve-out pharmacy benefits from the health plans.the b. The JHCC will review the procedure for obtaining biotech drugs and upon recommendation of the JHCC, the Director of DAS may require that such biotech drugs be obtained from specialty pharmacies. Furthermore, upon recommendation from the JHCC, the Director of DAS may establish a separate cost-sharing structure for biotech or lifestyle drugs. c. After consultation with the JHCC JHCC, the Director of DAS may implement the following: (1) Alternative pharmacy cost-sharing plan options such as co-insurance. (2) Coverage of certain Over-the-Counter (OTC) drugs. (3) Alternative pharmacy procurement and distribution channels. (4) Establishment of a special retail generic program. (5) Establishment of a retail 90 day maintenance drug program. d. No health plan The pharmacy vendor may not remove from its formulary or require preauthorization for any prescription drug that is among its ten most frequently prescribed drugs unless the health plan pharmacy vendor has notified the Employer and consulted with the JHCC, including in that consultation a review of the health plan research recommending that the drug be excluded or put on preauthorization status. e. Retail pharmacy program. There will be a retail pharmacy program for short- term (up to thirty (30) days) prescriptions, with easy access to pharmacies throughout the state. Commencing July 1, 2006, co-pays for a thirty (30) day supply of prescription drugs including coverage of prescriptions from a licensed dentist are: $10 co-payment for generic, twenty dollar ($20) co-pay for a formulary brand name drug, and a forty dollar ($40) co- co-pay for a non-non- formulary brand name drug. Where a generic equivalent is available, the co-co- pay for a non-formulary brand name drug shall be forty dollar ($40) and the difference in cost between the generic equivalent and the non-formulary brand name drug. Commencing July 1, 2007 the following drug co- co-pays shall apply. Co-pays for a thirty (30) day supply of prescription drugs including coverage of prescriptions from a licensed dentist are: ten dollar ($10) co-payment for generic, twenty-two dollar ($22) co-pay for a formulary brand name drug, and a forty-four dollar ($44) co-pay for a non-formulary brand name drug. Where a generic equivalent is available, the co-pay for a non-formulary brand name drug shall be forty- four dollar ($44) and the difference in cost between the generic equivalent and the non-formulary brand name drug. Commencing July 1, 2008, the following drug co-pays shall apply. Co-pays for a thirty (30) day supply of prescription drugs including coverage of prescriptions from a licensed dentist are: $10 co-payment for generic, twenty-five dollar ($25) co-pay for a formulary brand name drug and a fifty dollar ($50) co-pay for a non-formulary brand name drug. Where a generic equivalent is available, the co-pay for a non- formulary brand name drug shall be fifty dollar ($50) and the difference in cost between the generic equivalent and the non- formulary brand name drug. f. Mail Order Drug Program When a prescription for long-term or maintenance medications lasting more than thirty (30) days is necessary, persons enrolled in Ohio Med must use the mail order program for long-term maintenance drugs after the second prescription fill at retail. From July 1, 2006 through June 30, 2007, the following co-pays for mail order prescriptions of ninety (90) days shall apply. For a generic drug the co-pay is twenty-five dollars ($25). The co-pay is fifty dollars ($50) for a formulary brand name drug, and one hundred dollars ($100) for a non- formulary brand name drug. Where a generic equivalent is available, the co-pay for a non-formulary brand name drug is one hundred dollars $100 and the difference in cost between the generic equivalent and the non-formulary brand name drug. Commencing July 1, 2007, the following co-pays for mail order prescriptions of ninety (90) days shall apply. For a generic drug the co-pay is twenty-five dollars ($25). The co- pay is fifty-five dollars ($55) for a formulary brand name drug, and one hundred ten dollars ($110) for a non-formulary brand name drug. Where a generic equivalent is available, the co-pay for a non-formulary brand name drug is one hundred ten dollars ($110) and the difference in cost between the generic equivalent and the non-formulary brand name drug. Commencing July 1, 2008 the following co-pays for mail order prescriptions of ninety (90) days shall apply. For a generic drug the co-pay is twenty-five dollars ($25). For a formulary brand name drug the co-pay is sixty-two dollars and fifty cents ($62.50). For a non-formulary brand name drug the co-pay is one hundred twenty-five dollars ($125). Where a generic equivalent is available the co-pay for a non-formulary brand name drug shall be one hundred twenty-five dollars ($125) and the difference in cost between the generic equivalent and the non-formulary brand name drug. g. Prior Authorizations and Exclusions for Prescription Drug Programs (1) Prior Authorization. A number of prescription drugs require prior authorization, all approvals for such prescriptions will be handled by the Pharmacy Benefit Manager (PBM). During the life of this contract other drugs may be added to the list of prior authorization after consultation with the JHCC, if required. (2) It is recognized that certain drugs may not be covered by the plans.and