Common use of Specialty Pharmacy Guideline Management Clause in Contracts

Specialty Pharmacy Guideline Management. a program that is designed to support the member to ensure appropriate utilization for specialty medications. The program helps ensure the member meets sophisticated and robust criteria before a first dispense, helps ensure that the member experiences expected therapeutic outcomes while on therapy, and engages with the member’s provider to ensure that therapy is appropriate and that unsafe or ineffective therapy is discontinued. In instances where the treating physician disagrees with the recommendations of the PBM as to which medication to prescribe for the member the physician’s prescribing recommendation shall prevail except in instances where filling that prescription would violate Federal or State laws, guidelines, and/or regulations. In those instances where the treating physician’s recommendation prevails, the member shall not be required to pay more than the member’s cost identified in the prescription plan negotiated between the Union and the Employer requires.

Specialty Pharmacy Guideline Management. a program that is designed to support the member to ensure appropriate utilization for specialty medications. The program helps ensure the member meets sophisticated and robust criteria before a first dispense, helps ensure that the member experiences expected therapeutic outcomes while on therapy, and engages with the member’s provider to ensure that therapy is appropriate and that unsafe or ineffective therapy is discontinued. In instances where the treating physician disagrees with the recommendations of the PBM as to which medication to prescribe for the member the physician’s prescribing recommendation shall prevail except in instances where filling that prescription would violate Federal or State laws, guidelines, and/or regulations. In those instances where the treating physician’s recommendation prevails, the member shall not be required to pay more than the member’s cost identified in the prescription plan negotiated between the Union and the Employer requires.and/or