Specialty Drugs, Limited Distribution Drugs, and Physician Sample Clauses

Specialty Drugs, Limited Distribution Drugs, and Physician. Administered Drugs The Contractor shall coordinate the State’s pharmacy benefit management programs and services with the Contractor’s specialty pharmacy services in order to better support beneficiaries in managing complex health conditions. In addition, the Contractor shall assist the State in managing the increasingly high cost of specialty drugs through clinical and utilization management and consultative support to identify the optimal clinical management, site of dispensing, and site of service for the State. This shall encompass at a minimum specialty pharmaceuticals, limited distribution drugs, and physician-administered drugs. With the State’s input and cooperation, the Contractor shall create, administer, and maintain an overall strategy for the State to manage physician-administered drugs. This must include the breadth of clinical and utilization management services such as drug utilization review, prior authorization, step- therapy, quantity limits, and PDL management and support. It must also include consultative support to identify the optimal site of service, and may also include claims adjudication.
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Related to Specialty Drugs, Limited Distribution Drugs, and Physician

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Prosthetic devices replace or substitute all or part of an internal body part, including contiguous tissue, or replace all or part of the function of a permanently inoperative or malfunctioning body part and alleviate functional loss or impairment due to an illness, injury or congenital defect. Prosthetic devices do not include dental prosthetics. This plan covers the following prosthetic devices as required under R.I. General Law § 27-20-52: • prosthetic appliances such as artificial limbs, breasts, larynxes and eyes; • replacement or adjustment of prosthetic appliances if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired; • devices, accessories, batteries and supplies necessary for prosthetic devices; • orthopedic braces except corrective shoes and orthotic devices used in connection with footwear; and • breast prosthesis following a mastectomy, in accordance with the Women’s Health and Cancer Rights Act of 1998 and R.I. General Law 27-20-29. The prosthetic device must be ordered or provided by a physician, or by a provider under the direction of a physician. When you are prescribed a prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the outpatient benefit limit will apply. 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This plan covers hair prosthetics (wigs) worn for hair loss suffered as a result of cancer treatment in accordance with R.I. General Law § 27-20-54 and subject to the benefit limit and copayment listed in the Summary of Medical Benefits. This plan will reimburse the lesser of the provider’s charge or the benefit limit shown in the Summary of Medical Benefits. If the provider’s charge is more than the benefit limit, you are responsible for paying any difference. This plan covers Early Intervention Services in accordance with R.I. General Law §27- 20-50. Early Intervention Services are educational, developmental, health, and social services provided to children from birth to thirty-six (36) months. The child must be certified by the Rhode Island Department of Human Services (DHS) to enroll in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider and rendered to a Rhode Island resident. 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