Prescription Drug Services Sample Clauses

Prescription Drug Services. ‌ The Contractor shall provide pharmacy services to Members enrolled in the MississippiCAN Program. The Contractor shall comply with the Mississippi Pharmacy Practice Act and the Mississippi Board of Pharmacy rules and regulations. The Contractor is restricted from requiring Members to utilize a pharmacy that ships, mails, or delivers prescription drugs or devices. However, the Contractor may implement a mail-order pharmacy program in accordance with State and Federal law. The Contractor must use the most current version of the Medicaid Program Preferred Drug List (PDL), which is subject to periodic changes. The Contractor must use the Medicaid PDL developed by the Division or its Agent and may not develop and use its own PDL. The Contractor will be provided opportunities to offer feedback on the PDL to the Pharmacy and Therapeutics Committee, which is an advisory panel that conducts in-depth clinical evaluations and recommends appropriate drugs for preferred status on the PDL and/or drugs for Prior Authorization. The Executive Director of the Division has final authority on drugs with preferred status on the PDL and/or drugs for Prior Authorization. Refer to the Pharmacy Services page on the Division’s website for a current listing of prescription drugs on the PDL to ensure continuity of care for Members. The Contractor may approve drugs outside the PDL in accordance with Section 5.J, Prior Authorizations, of this Contract. The Contractor must cover and pay for a minimum of a three (3)-day emergency supply of prior authorized drugs until authorization is completed. The Contractor shall ensure that prescription drugs are prescribed and dispensed in accordance with medically accepted indications for uses and dosages. No payment may be made for services, procedures, supplies or drugs which are still in clinical trials and/or investigative or experimental in nature. The Contractor may consider exceptions to the criteria if there is sufficient documentation of stable therapy as reflected in ninety (90) calendar days of paid Medicaid claims. The Contractor is not authorized to negotiate rebates with drug companies for preferred pharmaceutical products. The Division or its Agent will negotiate rebate agreements. If the Contractor or its Subcontractor has an existing rebate agreement with a manufacturer, all Medicaid outpatient drug claims, including Provider-administered drugs, must be exempt from such rebate agreements. Please refer to Mississippi Administrativ...

Prescription Drug Services. (a) The Prescription Drug Program will cover medically necessary drugs requiring a physician's prescription and dispensed by a licensed pharmacist. Coverage will be provided under the Empire Plan Prescription Drug Program for prescription vitamins and contraceptives.

Prescription Drug Services. The term “

Prescription Drug Services. (a) The Prescription Drug Program will cover medically necessary drugs requiring a physician's prescription and dispensed by a licensed pharmacist. Coverage will be provided under the Empire Plan Prescription Drug Program for prescription vitamins and contraceptives. (b) Mandatory generic substitution will be required for all brand name multi source prescription drugs (a brand name drug with a generic equivalent) covered by the Prescription Drug Program. On a case-by-case basis, when a physician provides sufficient medical justification of the need for a brand name drug where a generic equivalent is available, the Program administrator will review the physician's request and rule on the appropriateness of a waiver of the mandatory generic substitution

Prescription Drug Services. (a) The Prescription Drug Program will cover medically necessary drugs requiring a physician's prescription and dispensed by a licensed pharmacist. Coverage shall be provided under the Empire Plan Prescription Drug Program for prescription vitamins and contraceptives. (b) The Prescription Drug Program will continue to utilize a preferred provider community pharmacy network. (c) Mandatory generic substitution shall be required for all brand-name multisource prescription drugs (a brand-name drug with a generic equivalent) covered by the Prescription Drug Program. To appeal this requirement, a physician must provide sufficient medical justification of the need for a brand-name drug where a generic equivalent is available. The Program administrator will review the physician's request and rule on the appropriateness of a waiver of the mandatory generic substitution. (1) Effective April 1, 2010, Level One shall be reserved for Generic Drugs, and may include brand name medications that are determined by the Prescription Drug Insurer/Administrator to be a “best value.” Generic drugs, that are determined not to add value to the Plan or the enrollee, may be placed in Level 2 or Level 3. (2) The copayment for any brand name drug placed in Level 1 shall be the same as the Level One copayment, similarly, any generic drug placed in Levels 2 or 3 will have the same copayment as brand name drugs in that level. (3) When a brand-name prescription drug is dispensed and an FDA- approved generic equivalent is available, the member shall be responsible for the difference in cost between the generic drug and the brand-name drug, plus the non-preferred brand level three copayment; not to exceed the cost of the drug. (4) A third level of prescription drugs and prescription copayments was created to differentiate between preferred brand-name and non- preferred brand-name drugs.

Prescription Drug Services. The Contract must provide Pharmacy Benefit Management (PBM) services as necessary to meet the requirements of the HRPP. These services include, but are not limited to: Provide retail, Mail Order Services, and Specialty Drug benefit programs and a pharmacy network with convenient access for Members. Provide claim services, claim eligibility verification, claim payment or denial, claims tracking and review of claim appeals. Manage the provider network, which is expected to provide one or more participating pharmacies located within a convenient distance of enrollee residences, provided there is a pharmacy available. Provide utilization management programs, such as Prior Authorization, Clinical Authorization, Step Therapy, and Drug Quantity Management programs. Provide and manage a prescription drug formulary that ensures quality and maximizes savings through formulary management. Reduce and control the cost of prescription drugs. The Contractor must ensure and report that the following standards are included in new, renewing or amended contracts with vendors (Subcontractors) providing a retail pharmacy network and/or a mail order pharmacy to enrollees (hereafter “PBM”) effective on or after the effective date of the Contract.

Prescription Drug Services. CITY desires to participate in BRMS’s arrangement with the Pharmacy Benefit Management Services (PBM) for the provision of prescription drug and drug utilization review services and mail order pharmacy program through the PBM pharmacy network, therefore, the parties agree that PBM shall provide the following services:

Prescription Drug Services. The Contractor shall provide pharmacy services either directly or through a subcontractor. -------------------------------------------------------------------------------- CONTRACT NO.: P0HC-2002-D-0003 62 -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- C.8.3.3.1 The Contractor may use a Pharmacy Benefit Manager (PBM) to process prescription claims if the proposed PBM subcontractor has received advance written approval from MAA. The PBM subcontract shall meet the requirements of this contract. If the Contractor elects to use a PBM, the administration of all denials, grievances, and appeals shall not be delegated to the PBM, but shall be handled by the Contractor. C.8.3.3.2 The Contractor may use a restricted formulary as long as it allows access to other drug products not on the formulary through some process such as prior authorization, complies with 42 U.S.C. Section 1396r-8(d) with respect to formularies, prior authorization, and other permissible limitations, and has been formally approved by MAA. C.8.3.3.3 The Contractor shall submit its formulary, including drugs subject to prior authorization or dispensing limitations, if any, for approval by MAA and shall notify MAA of any changes to the formulary on a quarterly basis. Approval will be provided by MAA within thirty (30) days of formulary submission. MAA may elect to use the Drug Utilization Review (DUR) Board for formulary reviews if it deems appropriate. The Contractor shall provide all medically necessary legend and non-legend drugs covered by the District of Columbia Medicaid Program. Plans may adopt a prescription formulary as long as it includes all items on the DC Medicaid formulary or their generic or therapeutic equivalents. A formulary shall not be used to deny coverage of any Medicaid-covered drug deemed medically necessary. C.8.3.3.4 If prior approval is used for certain drug categories, the Contractor shall provide MAA with a written protocol that describes how and when the prior approval process will be applied to formulary drug products. C.8.3.3.5 If the Contractor chooses to require prior authorization (either medical necessity or -------------------------------------------------------------------------------- CONTRACT NO.: P0HC-2002-D-0003 63 -------------------------------------------------------------------------------- -------------------------------------------------...

Prescription Drug Services a. The Prescription Drug Program will cover medically necessary drugs requiring a physician's prescription and dispensed by a licensed pharmacist. Coverage will be provided under the Empire Plan Prescription Drug Program for prescription vitamins and contraceptives. 1. The Prescription Drug Program will continue to utilize a preferred provider community pharmacy network. b. Mandatory generic substitution will be required for all brand-name multi-source prescription drugs (a brand-name drug with a generic equivalent) covered by the Prescription Drug Program. • On a case-by-case basis, when a physician provides sufficient medical justification of the need for a brand-name drug where a generic equivalent is available, the Program administrator will review the physician's request and rule on the appropriateness of a waiver of the mandatory generic substitution.

Prescription Drug Services. (a) The Prescription Drug Program will cover medically necessary drugs requiring a physician's prescription and dispensed by a licensed pharmacist. Coverage will be provided under the Empire Plan Prescription Drug Program for prescription vitamins and contraceptives. (a) (1) The Prescription Drug Program will continue to utilize a preferred provider community pharmacy network. (b) Mandatory generic substitution will be required for all brand-name multi- source prescription drugs (a brand-name drug with a generic equivalent) covered by the Prescription Drug Program. - On a case-by-case basis, when a physician provides sufficient medical justification of the need for a brand-name drug where a generic equivalent is available, the Program administrator will review the physician's request and rule on the appropriateness of a waiver of the mandatory generic substitution.