Common use of Prescription Drug Plans Clause in Contracts

Prescription Drug Plans. a. MCPS will implement a managed prescription drug plan that combines utilization review, physician profiling, and case-management techniques. The plan will protect a physician’s ability to make a final medical determination of the appropriate medication. The plan’s co-pay- ment structure is designed to encourage participants to purchase prescription drugs at the most affordable price. b. The prescription drug co-payment schedule will be as follows: Generic Drugs $5 $10 $5 $10 Brand Name, Formulary List Drugs $20 $25 $20 $25 Brand Name, Non-Formulary, no generic equivalent $35 $40 $35 $40 Brand Name, Non-Formulary, generic is available $35 plus the difference $40 plus the difference $35 plus the difference $40 plus the difference c. Generic Equivalent Rules—Prescriptions for non-formulary brand-name drugs with a generic equivalent will be filled automatically with a generic, and the participant will be charged the lower generic class co-pay. If the physician specifies to dispense as written, or if the participant opts for brand-name non-formulary drugs, such drugs will be dispensed and the co-pay shall include the added difference in cost for the name-brand drug over the generic drug. d. Formulary Drug List (a.k. a. “Primary Drug List”) is a list of preferred brand-name medi- cines that have been reviewed and selected by the pharmacy benefit manager’s “Pharmacy and Therapeutics Committee” of practicing doctors and clinical pharmacists for their safety, quality, and effectiveness. e. Maintenance Drug Class—Maintenance medications are drugs usually prescribed to treat conditions of a long-term or chronic nature, such as diabetes, arthritis, or high blood pres- sure. Drugs are classified according to therapeutic category and those drugs that are consid- ered as maintenance medications under the plan are identified through the pharmacy benefit manager. Two initial 30-day prescriptions for maintenance drugs may be filled at a retail phar- macy. Following that, maintenance drugs must be filled through the mail-order pharmacy program. If such subsequent maintenance drug prescriptions are purchased at a retail phar- macy, the plan shall pay only as much as it would have if the drug had been purchased by mail order—and the participant shall pay the difference. Participants may choose to continue purchasing their maintenance drugs in 30 day prescriptions at a retail pharmacy beyond the first two months. If they do, the co-pay shall be the mail order co-pay for a 30-day supply plus the added difference in cost for the retail maintenance drug over the plan’s cost for purchase of a 30-day supply of the maintenance drug through the mail-order pharmacy. f. Biotech Drug Class—Certain newly patented, high-cost, bioengineered drugs are to be bought in the most cost-effective way. The plan design shall include a specialty mail-order phar- macy for biotech drugs. The Joint Employee Benefits Committee will have responsibility for continuing to seek out ways to purchase biotech drugs at the lowest possible cost. g. Specialty Drugs—Caremark will be the exclusive provider of designated specialty drugs for Caremark plan participants. h. If a doctor certifies that it is medically necessary to prescribe a brand-name drug (for example, if the participant has an allergic reaction to the generic equivalent), the co-pay on brand-name drugs filled through the mail-order program will be the applicable brand-name drug co-pay— either formulary or non-formulary no-generic.

Prescription Drug Plans. a. MCPS will implement a managed prescription drug plan that combines com- xxxxx utilization review, physician profiling, and case-case management techniques. The plan will protect a physician’s ability to make a final medical determination of the appropriate medication. The plan’s co-pay- ment co- payment structure is designed to encourage participants to purchase prescription drugs at the most affordable price. b. The prescription drug co-payment schedule will be as follows: DRUG CLASS Retail Domestic Mail Order 30-day supply 3-month supply Generic Drugs $5 $10 $5 $10 Brand 0 Brand-Name, Formulary List Drugs $20 10 $25 $20 $25 Brand 10 Brand-Name, Non-Formularyformulary, no generic equivalent $35 25 $40 $35 $40 Brand 25 Brand-Name, Non-Formularyformulary, generic is available $35 25 plus the difference $40 plus the difference $35 plus the difference $40 25 plus the difference c. Generic Equivalent Rules—Prescriptions for non-formulary brand-brand name drugs with a generic equivalent will automatically be filled automatically with a generic, and the participant will be charged the lower generic class co-pay. If the physician specifies to dispense as written, or if the participant opts for brand-brand name non-formulary drugs, such drugs will be dispensed and the co-pay shall include the added difference in cost for the namebrand-brand name drug over the generic drug. d. Formulary Drug List Class (a.ka.k.a. a. , “Primary Drug ListClass”) is a list of preferred brand-brand name medi- cines medicines that have been reviewed and selected by the pharmacy benefit manager’s “Pharmacy and Therapeutics Committee” Committee of practicing doctors and clinical pharmacists for their safety, quality, and effectiveness. e. Maintenance Drug Class—Maintenance medications drugs are drugs usually prescribed to treat conditions of a long-term or chronic nature, such as diabetes, arthritis, or high blood pres- surepressure. Drugs are classified according to therapeutic category and those drugs that are consid- ered considered as maintenance medications under the plan and are identified through the pharmacy benefit manager. Two initial 30-day prescriptions for maintenance drugs may be filled at a retail phar- macypharmacy. Following that, maintenance drugs must be filled through the mail-order pharmacy programpharmacy. If such subsequent maintenance drug prescriptions are purchased at a retail phar- macypharmacy, the plan shall only pay only as much as it would have if the drug had been purchased by mail order—and the participant shall pay the difference. Participants may choose to continue purchasing their maintenance drugs in 30 30-day prescriptions at a retail pharmacy beyond the first two months. If they do, the co-pay shall be the mail order co-pay for a 30-day supply plus the added difference in cost for the retail maintenance drug over the plan’s plans cost for purchase of a 30-day supply of the maintenance drug through the mail-order pharmacy. f. Biotech Drug Class—Certain newly patented, high-cost, bioengineered bioengi- neered drugs are to be bought in the most cost-effective way. The plan design shall include a specialty mail-order phar- macy pharmacy for biotech drugs. The Joint Employee Benefits Committee will have responsibility responsibil- ity for continuing to seek out ways to purchase biotech drugs at the lowest possible cost. g. Specialty Drugs—Caremark will be the exclusive provider of designated specialty drugs for Caremark plan participants. h. If a doctor certifies that it is medically necessary to prescribe a brand-brand- name drug (for example, if the participant has an allergic reaction to the generic equivalent), the co-pay on brand-name drugs filled through the mail-mail order program will be the applicable brand-name drug co-pay— : either formulary or non-formulary nonon-generic. h. Network pricing at pharmacies participating in the network, and through the mail-order pharmacy, shall be made available to plan participants to purchase medical supplies not covered by the plan, but negotiated through the network. The co-pay for such supplies shall be 100 percent of the network discounted cost. i. Participants in the Xxxxxx Permanente HMO shall have their prescrip- tion coverage provided by Kaiser in conjunction with their medical plan. The co-pays shall be $5 for all prescriptions at Kaiser pharma- cies (including mail order) and $10 at other participating pharmacies (including Giant, Safeway, and CVS).

Prescription Drug Plans. a. MCPS will implement a managed prescription drug plan that combines utilization review, physician profiling, and case-management techniques. The plan will protect a physician’s ability to make a final medical determination of the appropriate medication. The plan’s co-pay- ment structure is designed to encourage participants to purchase prescription drugs at the most affordable price.. 2020–2023 ✦ MCAAP/MCBOA Agreement ✦ 33 b. The prescription drug co-payment schedule will be as follows: Generic Drugs $5 $10 $5 $10 Brand Name, Formulary List Drugs $20 $25 $20 $25 Brand Name, Non-Formulary, no generic equivalent $35 $40 $35 $40 Brand Name, Non-Formulary, generic is available $35 plus the difference $40 plus the difference $35 plus the difference $40 plus the difference c. Generic Equivalent Rules—Prescriptions for non-formulary brand-name drugs with a generic equivalent will be filled automatically with a generic, and the participant will be charged the lower generic class co-pay. If the physician specifies to dispense as written, or if the participant opts for brand-name non-formulary drugs, such drugs will be dispensed and the co-pay shall include the added difference in cost for the name-brand drug over the generic drug. d. Formulary Drug List (a.k. a. “Primary Drug List”) is a list of preferred brand-name medi- cines that have been reviewed and selected by the pharmacy benefit manager’s “Pharmacy and Therapeutics Committee” of practicing doctors and clinical pharmacists for their safety, quality, and effectiveness. e. Maintenance Drug Class—Maintenance medications are drugs usually prescribed to treat conditions of a long-term or chronic nature, such as diabetes, arthritis, or high blood pres- sure. Drugs are classified according to therapeutic category and those drugs that are consid- ered as maintenance medications under the plan are identified through the pharmacy benefit manager. Two initial 30-day prescriptions for maintenance drugs may be filled at a retail phar- macy. Following that, maintenance drugs must be filled through the mail-order pharmacy program. If such subsequent maintenance drug prescriptions are purchased at a retail phar- macy, the plan shall pay only as much as it would have if the drug had been purchased by mail order—and the participant shall pay the difference. Participants may choose to continue purchasing their maintenance drugs in 30 day prescriptions at a retail pharmacy beyond the first two months. If they do, the co-pay shall be the mail order co-pay for a 30-day supply plus the added difference in cost for the retail maintenance drug over the plan’s cost for purchase of a 30-day supply of the maintenance drug through the mail-order pharmacy. f. Biotech Drug Class—Certain newly patented, high-cost, bioengineered drugs are to be bought in the most cost-effective way. The plan design shall include a specialty mail-order phar- macy for biotech drugs. The Joint Employee Benefits Committee will have responsibility for continuing to seek out ways to purchase biotech drugs at the lowest possible cost. g. Specialty Drugs—Caremark will be the exclusive provider of designated specialty drugs for Caremark plan participants. h. If a doctor certifies that it is medically necessary to prescribe a brand-name drug (for example, if the participant has an allergic reaction to the generic equivalent), the co-pay on brand-name drugs filled through the mail-order program will be the applicable brand-name drug co-pay— either formulary or non-formulary no-generic.

Prescription Drug Plans. a. MCPS will implement a managed prescription drug plan that combines utilization review, physician profiling, and case-management case manage- ment techniques. The plan will protect a physician’s ability to make a final medical determination of the appropriate medication. The plan’s co-pay- ment payment structure is designed to encourage participants to purchase prescription drugs at the most affordable price. b. The prescription drug co-payment schedule will be as followsbe: DRUG CLASS Retail Domestic Mail Order Generic Drugs $5 $10 $5 $10 0 Brand Name, Formulary List Drugs $20 10 $25 $20 $25 10 Brand Name, Non-Formulary, no generic equivalent $35 25 $40 $35 $40 25 Brand Name, Non-Formulary, generic is available $35 25 plus the difference $40 plus the difference $35 plus the difference $40 25 plus the difference c. Generic Equivalent Rules—Prescriptions for non-formulary brand-brand name drugs with a generic equivalent will automatically be filled automatically with a generic, and the participant will be charged the lower generic class co-pay. If the physician specifies to dispense as written, or if the participant opts for brand-brand name non-formulary drugs, such drugs will be dispensed and the co-pay shall include the added difference in cost for the name-name brand drug over the generic drug. d. Formulary Drug List Class (a.ka.k.a. a. , “Primary Drug ListClass”) is a list of preferred brand-brand name medi- cines medicines that have been reviewed and selected by the pharmacy benefit manager’s “Pharmacy and Therapeutics Committee” of practicing doctors and clinical pharmacists for their safety, quality, and effectiveness. e. Maintenance Drug Class—Maintenance medications drugs are drugs usually prescribed to treat conditions of a long-term or chronic nature, such as diabetes, arthritis, or high blood pres- surepressure. Drugs are classified according to therapeutic category and those drugs that are consid- ered considered as maintenance medications under the plan are identified through the pharmacy benefit manager. Two initial 30-day prescriptions for maintenance drugs may be filled at a retail phar- macypharmacy. Following that, maintenance drugs must be filled through the mail-order pharmacy programpharmacy. If such subsequent maintenance drug prescriptions are purchased at a retail phar- macypharmacy, the plan shall only pay only as much as it would have if the drug had been purchased by mail mail-order—and the participant shall pay the difference. Participants may choose to continue purchasing their maintenance drugs in 30 30-day prescriptions at a retail pharmacy beyond the first two months. If they do, the co-pay shall be the mail order co-pay for a 30-day supply plus the added difference in cost for the retail maintenance drug over the plan’s plans cost for purchase of a 30-day supply of the maintenance drug through the mail-order pharmacy. f. Biotech Drug Class—Certain newly newly-patented, high-cost, bioengineered bio-engi- neered drugs are to be bought in the most cost-effective way. The plan design shall include a specialty mail-order phar- macy pharmacy for biotech drugs. The Joint Employee Benefits Committee will have responsibility responsi- bility for continuing to seek out ways to purchase biotech drugs at the lowest possible cost. g. Specialty Drugs—Caremark will be the exclusive provider of designated specialty drugs for Caremark plan participants. h. If a doctor certifies that it is medically necessary to prescribe a brand-brand name drug (for example, if the participant has an allergic reaction to the generic equivalent), the co-pay on brand-brand name drugs filled through the mail-mail order program will be the applicable brand-brand name drug co-pay— : either formulary or non-formulary nonon-generic. h. Network pricing at pharmacies participating in the network, and through the mail order pharmacy, shall be made available to plan participants to purchase medical supplies not covered by the plan, but negotiated through the network. The co-pay for such supplies shall be 100 percent of the network discounted cost. i. Participants in the Kaiser HMO shall have their prescription coverage provided by Kaiser in conjunction with their medical plan. The co-pays shall be $5 for all prescriptions at Kaiser pharmacies (including mail-order) and $10 at other participating pharmacies (including Giant, Safeway, and CVS).

Prescription Drug Plans. a. MCPS will implement a managed prescription drug plan that which combines utilization review, physician profiling, profiling and case-case management techniquestech- niques . The plan will protect a physician’s ability to make a final medical determination of the appropriate medicationmedication . The plan’s co-pay- ment payment structure is designed to encourage participants to purchase prescription drugs at the most affordable priceaf- fordable price . b. The prescription drug co-payment schedule will be as followsbe: Generic Drugs $5 $10 $5 $10 Brand Name, Formulary List Drugs $20 $25 $20 $25 Brand Name, Non-Formulary, no generic equivalent $35 $40 $35 $40 Brand Name, Non-Formulary, generic is available $35 plus the difference $40 plus the difference $35 plus the difference $40 plus the differencedrug Class domestic retail 30 day supply Mail order 3- month supply arTiCLe c. Generic generic Equivalent Rules—Rules — Prescriptions for non-formulary brand-brand name drugs with a generic equivalent will automatically be filled automatically with a generic, and the participant will be charged the lower generic class co-paypay . If the physician specifies to dispense as written, or if the participant par- ticipant opts for brand-brand name non-formulary drugs, such drugs will be dispensed and the co-pay shall include the added difference in cost for the name-name brand drug over the generic drugdrug . d. Formulary Drug List (a.ka .k . a. a . “Primary Drug List”) is a list of preferred brand-brand name medi- cines medicines that have been reviewed and selected by the pharmacy benefit manager’s “Pharmacy and Therapeutics Committee” of practicing doctors and clinical pharmacists for their safety, quality, quality and effectivenesseffectiveness . e. Maintenance Drug Class—Class — Maintenance medications are drugs usually prescribed to treat conditions of a long-term or chronic nature, such as diabetes, arthritis, or high blood pres- surepressure . Drugs are classified according to therapeutic category and those drugs that are consid- ered considered as maintenance medications under the plan are identified through the pharmacy benefit managermanager . Two initial 30-day prescriptions for maintenance drugs may be filled at a retail phar- macypharmacy . Following that, maintenance drugs must be filled through the mail-order pharmacy program. If such subsequent maintenance drug prescriptions pre- scriptions are purchased at a retail phar- macypharmacy, the plan shall only pay only as much as it would have if the drug had been purchased by mail order—mail-order – and the participant shall pay the differencedifference . Participants may choose to continue purchasing their maintenance main- tenance drugs in 30 30-day prescriptions at a retail pharmacy beyond the first two monthsmonths . If they do, the co-pay shall be the mail order co-pay for a 30-day supply plus the added difference in cost for the retail maintenance drug over the plan’s cost for purchase of a 30-day supply of the maintenance drug through the mail-order pharmacypharmacy . f. Biotech Drug Class—Class — Certain newly newly-patented, high-cost, bioengineered bio-engineered drugs are to be bought in the most cost-effective wayway . The plan design shall include a specialty mail-order phar- macy for biotech drugs. The Joint Employee Benefits Committee will have responsibility for continuing to seek out ways to purchase biotech drugs at the lowest possible cost.order g. Specialty Drugs—Caremark will be the exclusive provider of designated specialty drugs for Caremark plan participants. h. If a doctor certifies that it is medically necessary to prescribe a brand-brand name drug (for example, if the participant has an allergic reaction to the generic equivalent), the co-pay on brand-brand name drugs filled through the mail-mail order program will be the applicable brand-brand name drug co-pay— : either formulary or non-formulary no-genericgeneric . h. Network pricing at pharmacies participating in the network, and through the mail order pharmacy, shall be made available to plan par- ticipants to purchase medical supplies not covered by the plan but negotiated through the network . The co-pay for such supplies shall be 100 percent of the network discounted cost . i. Participants in the Kaiser HMO shall have their prescription coverage provided by Kaiser in conjunction with their medical plan . The co- pays shall be $5 for all prescriptions at Kaiser pharmacies (including mail-order) and $10 at other participating pharmacies (including Giant, Safeway, and CVS) .

Prescription Drug Plans. a. MCPS will implement a managed prescription drug plan that combines utilization review, physician profiling, and case-management techniques. The plan will protect a physician’s ability to make a final medical determination of the appropriate medication. The plan’s co-pay- ment structure is designed to encourage participants to purchase prescription drugs at the most affordable price. b. The prescription drug co-payment schedule will be as follows: Generic Drugs $5 $10 $5 $10 Brand Name, Formulary List Drugs $20 $25 $20 $25 Brand Name, Non-Formulary, no generic equivalent $35 $40 $35 $40 Brand Name, Non-Formulary, generic is available $35 plus the difference $40 plus the difference $35 plus the difference $40 plus the difference c. Generic Equivalent Rules—Prescriptions for non-formulary brand-name drugs with a generic equivalent will be filled automatically with a generic, and the participant will be charged the lower generic class co-pay. If the physician specifies to dispense as written, or if the participant opts for brand-name non-formulary drugs, such drugs will be dispensed and the co-pay shall include the added difference in cost for the name-brand drug over the generic drug. d. Formulary Drug List (a.k. a. “Primary Drug List”) is a list of preferred brand-name medi- cines that have been reviewed and selected by the pharmacy benefit manager’s “Pharmacy and Therapeutics Committee” of practicing doctors and clinical pharmacists for their safety, quality, and effectiveness.Pharmacy e. Maintenance Drug Class—Maintenance medications are drugs usually prescribed to treat conditions of a long-term or chronic nature, such as diabetes, arthritis, or high blood pres- sure. Drugs are classified according to therapeutic category and those drugs that are consid- ered as maintenance medications under the plan are identified through the pharmacy benefit manager. Two initial 30-day prescriptions for maintenance drugs may be filled at a retail phar- macy. Following that, maintenance drugs must be filled through the mail-order pharmacy program. If such subsequent maintenance drug prescriptions are purchased at a retail phar- macy, the plan shall pay only as much as it would have if the drug had been purchased by mail order—and the participant shall pay the difference. Participants may choose to continue purchasing their maintenance drugs in 30 day prescriptions at a retail pharmacy beyond the first two months. If they do, the co-pay shall be the mail order co-pay for a 30-day supply plus the added difference in cost for the retail maintenance drug over the plan’s cost for purchase of a 30-day supply of the maintenance drug through the mail-order pharmacy. f. Biotech Drug Class—Certain newly patented, high-cost, bioengineered drugs are to be bought in the most cost-effective way. The plan design shall include a specialty mail-order phar- macy for biotech drugs. The Joint Employee Benefits Committee will have responsibility for continuing to seek out ways to purchase biotech drugs at the lowest possible cost. g. Specialty Drugs—Caremark will be the exclusive provider of designated specialty drugs for Caremark plan participants. h. If a doctor certifies that it is medically necessary to prescribe a brand-name drug (for example, if the participant has an allergic reaction to the generic equivalent), the co-pay on brand-name drugs filled through the mail-order program will be the applicable brand-name drug co-pay— either formulary or non-formulary no-generic.