Specialty Pharmacy. The City’s Pharmacy Benefits Manager (PBM) will determine which drugs are included in any or all of these clinical programs and the applicable quantity level limits subject to the restrictions noted above.
Specialty Pharmacy. A pharmacy which dispenses biotech drugs for rare and chronic diseases via scheduled drug delivery either to the Member’s home or to a Physician’s office. These pharmacies also provide telephonic therapy management to ensure safety and compliance. Correction of subluxations in the body to remove nerve interference or its effects. Interference must be the result of or related to distortion, misalignment or subluxation of or in the vertebral column.
Specialty Pharmacy. Claim Administrator and Prime have contracted with Specialty Pharmacies and/or vendors to provide Members with access to in-network benefits for covered Specialty Drugs.
Specialty Pharmacy. Notwithstanding the foregoing, the clinical programs described herein shall not impair a member’s right to appeal any adverse decision in accordance with the appeals rights described in the SPD. Further, a member or the member’s physician may seek an exception to one or more otherwise applicable clinical programs listed above.
Specialty Pharmacy. PBM shall provide the following services from its specialty pharmacy:
(i) receive prescriptions for Specialty Drugs, as identified in the Specialty Drug List (which is a fixed list amended from time to time under rules described in Exhibit C), subject to and in accordance with the Plan Design Document.
(ii) fill prescriptions, subject to the professional judgment of the dispensing pharmacist via U.S. mail or commercial carrier or facsimile machine at an address or telephone number specified by PBM from time to time;
(iii) provide Members dedicated toll-free telephone access to a pharmacist and customer service representatives;
(iv) provide to Participating Group promotional materials that explain to Members how to use the specialty service program, as well as any other materials Members may require to begin using the specialty program and Participating Group shall distribute such information to Members;
(v) provide computerized drug interaction monitoring of Members based upon the Member profile, programs for generic substitution and therapeutic intervention, pharmaceutical cost containment services and safety edits, and subject to prescriber approval, clinical appropriateness, the terms of the Participating Group Plan and applicable law;
(vi) ship all prescription orders to Members via U.S. Postal Service or other appropriate carrier to the address provided by Participating Group and/or the Member, as long as such addresses are located in the United States or location that permits delivery of prescriptions through such means; and
(vii) not dispense drugs if the prescription is not accompanied by the Cost Sharing as applicable.
(viii) New Specialty Drugs that fall into an existing therapeutic class will be priced at that therapeutic class rate as set forth under Exhibit C. This provision shall include any drugs that PBM deems to be a bio- similar product.
(ix) A Participating Group without incurring an increase in specialty drug discount costs from PBM. Neither Client nor CCOG may contract with an additional Specialty Vendor on behalf of Participating Groups. (x) ii) Specialty Pharmacy contracted rate plus zero charge for the product or (iv) Ingredient Cost Submitted.
Specialty Pharmacy. A pharmacy that dispenses generally low volume and high cost medications to patients who are undergoing intensive therapies for illnesses that are generally chronic, complex and potentially life threatening. Often these therapies require specialized delivery and administration. Require patient counseling/ support/compliance management.
Specialty Pharmacy. A pharmacy that has a contract with Us and is designated by Us as a Specialty Pharmacy who provides certain Covered Drugs, including, but not limited to, Prescription Drugs and Self- Administered Injectable and Specialty Drugs Orders or Refills.
Specialty Pharmacy. As elected by Sponsor on the Set-Up Forms, Members may have prescriptions filled through ESI Specialty Pharmacy on an exclusive basis (i.e., “ESI Specialty Pharmacy – Exclusive Care”) or at Participating Pharmacies and through ESI Specialty Pharmacy (i.e., “ESI Specialty Pharmacy – Open Care”). Subject to applicable law, ESI and ESI Specialty Pharmacy may communicate with Members and physicians to advise Members filling Specialty Products at Participating Pharmacies of the availability of filling prescriptions through ESI Specialty Pharmacy.
(i) ESI will notify Sponsor and Aon Xxxxxx monthly of any new Specialty Products that are introduced to the market on or after the Effective Date of this Agreement with their applicable reimbursement rates (“Notice”). Only newly FDA-approved and launched Specialty Products may be considered for addition to the Specialty Product List. Notice will be provided in advance of any modification with an explanation of the rationale for such modification. On a quarterly basis on the first business day of the first month of the quarter, ESI shall provide Aon Xxxxxx and Sponsor with a revised and complete Specialty Product List noting the effective date for each modification. The parties agree as follows:
(A) If Sponsor has expressly excluded a specific therapy class or product on a Set-Up Form, Specialty Products in such excluded classes will automatically be deemed excluded from coverage and will reject as “NDC Not Covered” through Participating Pharmacies, Mail Service Pharmacy and ESI Specialty Pharmacy; otherwise, subject to (B) below, all other Specialty Products will be implemented as Covered Drugs at the rate specified in the applicable Specialty Product List or Notice. If Sponsor desires to cover otherwise excluded Specialty Products, Sponsor must notify ESI in writing that it desires to cover the Specialty Product before ESI will adjudicate as a Covered Drug, and if ESI receives such confirmation of coverage from Sponsor such Specialty Product will be loaded thereafter as a Covered Drug at the applicable reimbursement rate set forth in the Notice.
(B) Sponsor must notify ESI in writing if it wants to exclude the Specialty Product from coverage. The exclusion will be implemented within seven (7) business days after the date of ESI’s receipt of such notification. There will not be any retroactive denials for Prescription Drug Claims processed prior to ESI’s receipt of the rejection notice and implementation of the exclusi...
Specialty Pharmacy. Pricing proposal assumes an exclusive specialty arrangement with If a Participating Group requires other specialty pharmacy arrangements, the parties will discuss separate contractual terms and conditions on a case-by-case basis. Under an exclusive arrangement, grace fills at retail will not be allowed. New drugs are added as soon as they hit Medi-Span which is usually on the day or within a few days of product launch. Pricing is available around the same timeline. Newly FDA- approved products will be billed and reimbursed at the Default Rate of AWP 14%.
Specialty Pharmacy. Subject to Section 6.5 of this Agreement, Caremark shall be the exclusive provider of Specialty Drugs to Plan Participants and shall provide the products and services, listed in Exhibit C of the Pricing Agreement (the “Specialty Drug Exhibit”), as follows:
(a) Dispense new or refill prescription orders for Specialty Drugs upon receipt from a Plan Participant of (i) a prescription and a completed order or refill order form, and (ii) the applicable Cost Share;
(b) Fill prescriptions for Specialty Drugs subject to the professional judgment of the dispensing pharmacist, good pharmacy practices in accordance with local community standards, and product labeling and guidelines;
(c) Ship Specialty Drugs to Plan Participants via U. S. Postal Service or other appropriate carriers to the address provided by Participating Group and/or the Plan Participant;
(d) Bill major medical benefits through the use of a CMS 1500 form when required subject to pricing terms as outlined in the Pricing Agreement incorporated herein;
(e) Provide routine supplies required for the administration of the Specialty Drug (such as needles, syringes, alcohol swabs, etc.) to the extent deemed appropriate by Caremark.
