Pharmacy Coverage Clause Samples
The Pharmacy Coverage clause defines the terms under which prescription medications are included as part of a health insurance or benefits plan. It typically outlines which drugs are covered, any applicable copayments or deductibles, and the process for obtaining prescriptions, such as using in-network pharmacies or following formulary lists. This clause ensures that plan members understand their access to prescription drugs and helps manage costs and expectations regarding medication benefits.
Pharmacy Coverage a. Pharmacy Coverage HMOs must carve out all SSA §1927 covered outpatient drugs to fee-for-service (covered outpatient drugs include drugs dispensed in a pharmacy, administered in a doctor’s office, or clinic; drugs reimbursed at bundled rate are not considered outpatient drugs). Per Article III, section C, the HMO must coordinate the services it provides to members with services a member receives through Medicaid Fee-for-Service.
b. Pharmacy Services Lock-In Program DMS will manage a Pharmacy Services Lock-In Program to coordinate the provision of health care services for HMO members who abuse or misuse pharmacy benefits by seeking duplicate or medically unnecessary services, for restricted medications. Abuse or misuse is defined under Recipient Duties in DHS 104.02, Wisconsin Administrative Code. Restricted medications are most controlled substances and tramadol. HMO members enrolled in the Pharmacy Services Lock-In Program will be locked into one pharmacy where prescriptions for restricted medications must be filled and one primary prescriber who will prescribe restricted medications. HMO members will remain enrolled in the Pharmacy Services Lock-In Program for two years. At the end of the two-year enrollment period, DMS or the HMO will assess if the member should continue enrollment in the Pharmacy Services Lock-In Program. Policy on the Pharmacy Services Lock-In Program can be found in the BadgerCare Plus and Medicaid Pharmacy Provider Handbook.
Pharmacy Coverage a. Pharmacy Coverage Prescription, over-the-counter, diabetic and other drug related supplies (as defined by the Department), medication therapy management and provider administered drugs, under Article IV, A.1.j, is carved out of the nonrisk prepayment for the FCMH Program and will be paid on a fee-for-service basis.
Pharmacy Coverage a. Pharmacy Coverage Prescription, over-the-counter, diabetic and other drug related supplies (as defined by the Department), medication therapy management and provider administered drugs under Article IV, A.1.o, is carved out of the capitation rate for all BadgerCare Pus and/or Medicaid SSI members and will be paid on a fee-for-service basis. Per Article III, section C, the HMO must coordinate the services it provides to members with services a member receives through Medicaid Fee-for-Service.
Pharmacy Coverage. PIHPs must carve out all SSA §1927 covered outpatient drugs to fee-for- service (covered outpatient drugs include drugs dispensed in a pharmacy, administered in a doctor’s office, outpatient hospital or clinic; drugs reimbursed at bundled rate are not considered outpatient drugs).
Pharmacy Coverage. Chiropractic services, unless the HMO elects to provide chiropractic services.
Pharmacy Coverage. Medical Necessity The actual provision of any service is subject to the professional judgment of the HMO providers as to the medical necessity of the service, except that the HMO must provide assessment, evaluation, and treatment services ordered by a court. Decisions to provide or not to provide or authorize medical services shall be based solely on medical necessity and appropriateness as defined in HFS 101.03(96m). Disputes between the HMO and members about medical necessity can be appealed through the HMO grievance system, and ultimately to the Department for a binding determination; the Department’s determinations will be based on whether BadgerCare Plus and/or Medicaid SSI would have covered the service on a FFS basis (except for certain experimental procedures).
Pharmacy Coverage. Chiropractic services, unless the HMO elects to provide chiropractic services. Addendum V contains additional summary information on BadgerCare Plus and Medicaid SSI covered services. Please refer to the ForwardHealth Provider Updates for the most current information regarding BadgerCare Plus and/or Medicaid SSI covered services.
Pharmacy Coverage a. Pharmacy Coverage Prescription, over-the-counter, diabetic and other drug related supplies (as defined by the Department), medication therapy management and provider administered drugs under Article IV, A.1.o, is carved out of the capitation rate for all BadgerCare Pus and/or Medicaid SSI members and will be paid on a fee-for-service basis. Per Article III, section C, the HMO must coordinate the services it provides to members with services a member receives through Medicaid Fee-for-Service.
b. Pharmacy Services Lock-In Program DMS will manage a Pharmacy Services Lock-In Program to coordinate the provision of health care services for HMO members who abuse or misuse pharmacy benefits by seeking duplicate or medically unnecessary services, for restricted medications. Abuse or misuse is defined under Recipient Duties in DHS 104.02, Wisconsin Administrative Code. Restricted medications are most controlled substances and tramadol. HMO members enrolled in the Pharmacy Services Lock-In Program will be locked into one pharmacy where prescriptions for restricted medications must be filled and one primary prescriber who will prescribe restricted medications. HMO members will remain enrolled in the Pharmacy Services Lock-In Program for two years. At the end of the two-year enrollment period, DMS or the HMO will assess if the member should continue enrollment in the Pharmacy Services Lock-In Program. Policy on the Pharmacy Services Lock-In Program can be found in the BadgerCare Plus and Medicaid Pharmacy Provider Handbook.
Pharmacy Coverage a. Pharmacy Coverage Pharmacy coverage, including provider-administered drugs under Art. III, E, 3, is carved out of the capitation rate for all BadgerCare Plus and/or Medicaid SSI members and will be paid on a fee-for-service basis.