Preferred Drug List and Formulary Requirements Sample Clauses

Preferred Drug List and Formulary Requirements. The Contractor shall maintain a preferred drug list (PDL) for the Contractor’s Hoosier Healthwise packages. The Hoosier Healthwise formulary shall support the coverage and non-coverage requirements for legend and non-legend drugs by Indiana Medicaid. More information can be found in 000 XXX 0-00-0, 405 IAC 5-24-4, 405 IAC 5-24-5 and 407 IAC 3-10-1. Prior to implementing a PDL or formulary, the Contractor shall: (i) submit the PDL or formulary to OMPP for submission to the Drug Utilization and Review (DUR) Board; and (ii) receive approval from OMPP in accordance with IC 00-00-00-00. At least thirty-five (35) days before the intended implementation date of the PDL and formulary, the Contractor shall submit its proposed PDL and formulary to OMPP. The OMPP shall submit the PDL and formulary to the Drug Utilization Review (DUR) Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regarding the PDL and formulary. The DUR Board will provide a recommendation regarding approval of the PDL and formulary in accordance with the terms of IC 00-00-00-00. OMPP will approve, disapprove or modify the PDL and/or formulary based on the DUR Board’s recommendation. The Contractor shall comply with the decision within sixty (60) days after receiving notice of the decision. The Contractor shall utilize a Pharmacy and Therapeutics Committee which shall meet regularly to make recommendations for changes to the PDL and/or formulary. In accordance with IC 00-00-00-00, prior to removing one (1) or more drugs from the PDL and/or formulary or otherwise placing new PA criteria on one
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Preferred Drug List and Formulary Requirements. The Contractor shall maintain a preferred drug list (PDL) for the Contractor’s HIP program. The HIP formulary shall support the coverage and non-coverage requirements for legend drugs by Indiana Medicaid, found in 405 IAC 5-24-3. In accordance with CMS-2390-F, the Contractor shall demonstrate prescription drug coverage consistent with the amount, duration, and scope of the fee-for-service program. The Contractor shall engage with the State process to develop universal medically necessary prior authorization criteria for IHCP. The Contractor shall implement the universal IHCP criteria into their program and may not utilize more restrictive criteria. While the underlying drug formulary for the HIP Plus and the HIP Basic plans will be identical, additional pharmacy services will differ between the plans in order to align the benefits with the overall program goals aimed at encouraging member participation in HIP Plus. Therefore, the HIP Basic pharmacy benefit may have more restrictions than the HIP plus benefit, such as limiting prescription supplies to 30 days. Also, prescriptions obtained by a HIP Basic or HIP State Plan Basic member that are not otherwise exempt on the basis of being preventive, family planning, or maternity, are subject to the copayment amounts set forth in Section 4.1.2. Copayments assessed to the HIP Basic or HIP State Plan Basic member at the point of sale may not exceed the total cost of the drug. Similarly, the HIP Plus pharmacy benefit shall provide additional enhanced pharmacy services including the following: (i) ninety (90) day prescription supplies of routine maintenance medications, when requested by the member; (ii) mail order pharmacy benefit; (iii) and no copayment for any filled prescription. These additional pharmacy services shall only be made available to individuals participating in HIP Plus and HIP State Plan Plus benefits. Prior to implementing a PDL or formulary, the Contractor shall: (i) submit the PDL or formulary to OMPP for submission to the Drug Utilization and Review (DUR) Board; and (ii) receive approval from OMPP in accordance with IC 00-00-00-00. At least thirty-five (35) days before the intended implementation date of the PDL and formulary, the Contractor shall submit its proposed PDL and formulary to OMPP. The OMPP shall submit the PDL and formulary to the Drug Utilization Review (DUR) Board for review and recommendation. The Contractor shall be accessible to the DUR Board to respond to any questions regar...
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Preferred Drug List and Formulary Requirements. The Contractor shall maintain a preferred drug list (PDL) for the Contractor’s Hoosier Healthwise packages. The Hoosier Healthwise formulary shall support the coverage and non-coverage requirements for legend and non-legend drugs by Indiana Medicaid. More information can be found in 000 XXX 0-00-0, 405 IAC 5-24-4, 405 IAC 5-24-5 and 407 IAC 3-10-1. Prior to implementing a PDL or formulary, the Contractor shall: (i) submit the PDL or formulary to OMPP for submission to the Drug Utilization and Review (DUR) Board; and
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Preferred Drug List and Formulary Requirements. The Contractor shall maintain a preferred drug list (PDL) for the Contractor’s Hoosier Healthwise packages. The Hoosier Healthwise formulary shall support the coverage and non-coverage requirements for legend and non-legend drugs by Indiana Medicaid. More information can be found in 000 XXX 0-00-0, 405 IAC 5-24-4, 405 IAC 5-24-5 and 407 IAC 3-10-1. In accordance with CMS-2390-F, the Contractor shall demonstrate prescription drug coverage consistent with the amount, duration, and scope of the fee-for-service program. The Contractor shall EXHIBIT 1.E
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Preferred Drug List and Formulary Requirements. The Contractor shall maintain a preferred drug list (PDL) for the Contractor’s HIP program. The HIP formulary shall support the coverage and non-coverage requirements for legend drugs by Indiana Medicaid, found in 405 IAC 5-24- 3. While the underlying drug formulary for the HIP Plus and the HIP Basic plans will be identical, additional pharmacy services will differ between the plans in order to align the benefits with the overall program goals aimed at encouraging member participation in HIP Plus. Therefore, the HIP Basic pharmacy benefit may have more restrictions than the HIP plus benefit, such as limiting prescription supplies to 30 days. Also, prescriptions obtained by a HIP Basic or HIP State Plan Basic member that are not otherwise exempt on the basis of being preventive, family planning, or maternity, are subject to the copayment amounts set forth in Section 4.1.2. Copayments assessed to the HIP Basic or HIP State Plan Basic member at the point of sale may not exceed the total cost of the drug. Similarly, the HIP Plus pharmacy benefit shall provide additional enhanced pharmacy services including the following: (i) ninety (90) day prescription supplies of routine maintenance medications, when requested by the member;
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Related to Preferred Drug List and Formulary Requirements

  • Designated Prescription Drug Prescribers and Pharmacies We may limit your selection of a pharmacy to a single pharmacy location and/or a single prescribing provider or practice. Those members subject to this designation include, but are not limited to, members that have a history of: • being prescribed prescription drugs by multiple providers; • having prescriptions drugs filled at multiple pharmacies; • being prescribed certain long acting opioids and other controlled substances, either in combination or separately, that suggests a need for monitoring due to: o quantities dispensed; o daily dosage range; or o the duration of therapy exceeds reasonable and established thresholds. The Amount You Pay for Prescription Drugs Our formulary includes a tiered copayment structure, which means the amount you pay for a prescription drug will vary by tier. See the Summary of Pharmacy Benefits for your copayment structure, benefit limits and the amount you pay. When you buy covered prescription drugs and diabetic equipment and supplies from a retail network pharmacy, you will be responsible for the copayment and deductible (if any) at the time of purchase. You will be responsible for paying the lower of your copayment, the retail cost of the drug, or the pharmacy allowance. Specialty prescription drugs are generally obtained from a specialty pharmacy. If you buy a specialty prescription drug from a retail network pharmacy, you will be responsible for a significantly higher out of pocket expense than if you bought the specialty drug from a specialty pharmacy. The amount you pay for the following prescription drugs is not subject to the tiered copayment structure: • Contraceptive methods; • Over-the-counter (OTC) preventive drugs; • Nicotine replacement therapy (NRT) and smoking cessation prescription drugs; • Infertility specialty prescription drugs; and • Covered diabetic equipment or supplies bought at a network pharmacy. See the Summary of Pharmacy Benefits for benefit limits and the amount you pay. This plan allows for medication synchronization in accordance with R.I. General Law

  • Prescription Drug Program 1. It is agreed that the State shall continue the Prescription Drug Benefit Program during the period of this Agreement. The program shall be funded and administered by the State. It shall provide benefits to all eligible unit employees and their eligible dependents. Each prescription required by competent medical authority for Federal legend drugs shall be paid for by the State from funds provided for the Program subject to a deductible provision which shall not exceed $5.00 per prescription or renewal of such prescription and further subject to specific procedural and administrative rules and regulations which are part of the Program.

  • Alcohol and Drug Testing Employee agrees to comply with and submit to any Company program or policy for testing for alcohol abuse or use of drugs and, in the absence of such a program or policy, to submit to such testing as may be required by Company and administered in accordance with applicable law and regulations.

  • Prescription Drug any drugs or medications ordered by a Professional Provider by means of a valid prescription order, bearing the Federal legend: “Caution - Federal law prohibits dispensing without a prescription,” or legend drugs under applicable state law and dispensed by a licensed pharmacist. Also included are prescribed insulin and other pharmacological agents used to control blood sugar, diabetic supplies and insulin syringes.

  • Prescription Drug Quantity Limits We limit the quantity of certain prescription drugs that you can get at one time for safety, cost-effectiveness and medical appropriateness reasons. Our clinical criteria for quantity limits are subject to our periodic review and modification. Quantity limits may restrict: • the amount of pills dispensed per thirty (30) day period; • the number of prescriptions ordered in a specified time period; or • the number of prescriptions ordered by a provider, or multiple providers. Our formulary indicates which prescription drugs have a quantity limit. Types of Pharmacies Prescription drugs and diabetic equipment or supplies can be bought from the following types of pharmacies: • Retail pharmacies. These dispense prescription drugs and diabetic equipment or supplies. • Mail order pharmacies. These dispense maintenance and non-maintenance prescription drugs and diabetic equipment or supplies. • Specialty pharmacies. These dispense specialty prescription drugs, defined as such on our formulary. For information about our network retail, mail order, and specialty pharmacies, visit our website or call our Customer Service Department.

  • Random Drug Testing All employees covered by this Agreement shall be subject to random drug testing in accordance with Appendix D.

  • Federal Medicaid System Security Requirements Compliance Party shall provide a security plan, risk assessment, and security controls review document within three months of the start date of this Agreement (and update it annually thereafter) in order to support audit compliance with 45 CFR 95.621 subpart F, ADP System Security Requirements and Review Process.

  • label Prescription Drugs This plan covers off label prescription drugs for cancer or disabling or life-threatening chronic disease if the prescription drug is recognized as a treatment for cancer or disabling or life-threatening chronic disease in accepted medical literature, in accordance with R.I. General Law § 27-55-1.

  • Prescription Drug Plan Effective July 1, 2011, retail and mail order prescription drug copays for bargaining unit employees shall be as follows: Type of Drug Prescriptions for 1-45 Days (1 copay) Prescriptions for 46-90 Days (2 copays) Generic drug $10 $20 Preferred brand name drug $25 $50 Non-preferred brand name drug $40 $80 Effective July 1, 2011, for each plan year the Prescription Drug annual out-of- pocket copay maximum shall be $1,000 for individual coverage and $1,500 for employee and spouse, employee and child, or employee and family coverage.

  • Preferred Provider - Prescription Drugs The Board shall provide, through the Xxxxx County Council of Governments, a preferred provider drug program that, if the employee chooses to utilize, will include the following:

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