Drug Coverage Clause Samples

Drug Coverage. Prescription drugs, certain over-the-counter drugs, and pharmacy supplements are benefits under the Hoosier Care Connect program to be covered by the Contractor. The Contractor agrees to abide by 42 CFR 437-438.3(s), the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) and P.L. 115-271, “SUPPORT” Act. If directed as such by FSSA, the Contractor shall utilize a common or unified PDL/PA criteria, including discontinuation of commercial discount and commercial rebates agreements with pharmaceutical manufacturers for IHCP member pharmacy benefits, or consolidation of the pharmacy benefit under the FFS program. If the Contractor enters into a contract or agreement with a Pharmacy Benefit Manager (PBM) for the provision and administration of pharmacy services, the contract or agreement shall be developed as a pass-through pricing model as defined below: 1. All monies related to services provided for the Contractor are passed through to the Contractor, including but not limited to: dispensing fees and ingredient costs paid to pharmacies, and all revenue received, including but not limited to pricing discounts paid to the PBM, rebates (including manufacturer fees and administration fees for rebating), inflationary payments, and supplemental or commercial rebates; 2. All payment streams, including any financial benefits such as rebates, discounts, credits, clawbacks, fees, grants, reimbursements, or other payments that the PBM receives related to services provided for the Contractor are fully disclosed to the Contractor, and provided to the State upon request, and; 3. The PBM is paid an administrative fee which covers the cost of providing the PBM services as described in the PBM contract or agreement as well as margin. The payment model for the PBM’s administrative fee shall be made available to the State. If concerns are identified, the State reserves the right to request any changes be made to the payment model.

Drug Coverage. Prescription drugs and certain over-the-counter drugs are benefits under the Hoosier Care Connect program to be covered by the Contractor. Members are responsible for a copayment for covered drugs in the amount outlined in Section 12.

Drug Coverage. The Company will increase the life time maximum from ten thousand ($10,000.00) dollars to one hundred twenty thousand ($120,000.00) dollars for hospital, extended health and drug benefits for full-time employees.

Drug Coverage. Prescription drugs, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the HIP program to be covered by the Contractor. Per 21 § CFR 203.3, prescription drug means any drug (including any biological product, except for blood and blood components intended for transfusion or biological products that are also medical devices) required by Federal law (including Federal regulation) to be dispensed only by a prescription, including finished dosage forms and bulk drug substances subject to section 503(b) of the Social Security Act. The Contractor agrees to abide by 42 CFR 438.3(s), the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) and P.L. 115-271, “SUPPORT” Act. The Contractor shall follow the statewide unified preferred drug list (SUPDL) for the pharmacy benefit. The SUPDL will consist of the fee-for-service (FFS) PDL. Adoption of the SUPDL shall include alignment of prior authorization (PA), forms, and step edit and utilization edit criteria for drugs and drug classes that are part of the SUPDL. The Contractor will discontinue and not seek commercial discounts and commercial rebate agreements with pharmaceutical manufacturers for IHCP member pharmacy benefits. The Contractor may only set a Maximum Allowable Cost (MAC) rate on a multiple source drug available from at least two manufacturers. The MAC rate may not be applied when the brand product is preferred over available generics on the SUPDL. The Contractor shall assure proper and complete PBM agent training.

Drug Coverage. Prescription drugs, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Healthwise program to be covered by the Contractor. Per 21 § CFR 203.3, prescription drug means any drug (including any biological product, except for blood and blood components intended for transfusion or biological products that are also medical devices) required by Federal law (including Federal regulation) to be dispensed only by a prescription, including finished dosage forms and bulk drug substances subject to section 503(b) of the Social Security Act. The Contractor agrees to abide by 42 CFR 438.3(s), the Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) and P.L. 115-271, “SUPPORT” Act. The Contractor shall follow the statewide unified preferred drug list (SUPDL) for the pharmacy benefit. The SUPDL will consist of the fee-for-service (FFS) PDL. Adoption of the SUPDL shall include alignment of prior authorization (PA), forms, and step edit and utilization edit criteria for drugs and drug classes that are part of the SUPDL. The Contractor will discontinue and not seek commercial discounts and commercial rebate agreements with pharmaceutical manufacturers for IHCP member pharmacy benefits.

Drug Coverage. Effective June 1, 2017 the employer will provide each member with a drug card for direct billing of covered drugs. The employer advises that this new coverage is for generic drugs, unless the prescribing physician specifies a name brand.

Drug Coverage. The Company will contribute one hundred percent (100%) of the cost to provide an employee's coverage for the Prescription Drug Program. Each full-time employee upon completion of four hundred eighty (480) hours of work will be eligible for coverage under the Company provided Prescription Drug Program with the following benefits after a deductible of thirty-five cents for each prescription and refill. Coverage includes drugs which legally require a prescription to be dispensed, serums, and (needles, syringes and for use with insulin) purchased on the prescription of a medical doctor. It does not include vitamins and vitamin preparations (unless injected), patent or proprietary medicines, or drugs not approved for legal sale to the general public in Canada. The name, strength and quantity of the drug must be shown on all receipts. Effective October a substitution" rule will be implemented, which means the prescription drug coverage will only pay the price of a generic equivalent unless the physician indicates "no substitute" on the prescription, or if there is no generic equivalent to the brand name drug being dispensed. The Company will contribute one hundred percent (100%) of the cost to provide an employee's coverage for the Dental Insurance Program. Each full-time employee, upon completion of four hundred eighty (480) hours of work will be eligible for coverage under the Company provided Dental Insurance Program, under Dental Plan with Rider which provides certain Periodontal, Endodontic and Surgical Services, based on the then current Ontario Dental Association Schedule of Fees for Dental Services provided by Practitioners. Procedures currently limited to every six (6) months prior to December shall be limited to one each nine (9) months after such date. Effective October the Company agrees to improve the current dental benefit plan by adding the following benefits: reimbursement of charges for covered benefits up to the current fees specified in the Ontario Dental Association Fee Guide for Practitioners. reimbursement of charges for covered benefits up to the current fees specified in the Ontario Dental Association Fee Guide for General Practitioners.

Drug Coverage. The Contractor shall: 1) Cover all prescription and over-the-counter drugs as described in Appendix C, consistent with the MassHealth Drug List; 2) Operate and maintain a state-of-the-art National Council for Prescription Drug Programs (NCPDP)-compliant, on-line pharmacy claims processing system. Such system must allow for: a) Financial, eligibility, and clinical editing of claims; b) Messaging to pharmacies; c) Pharmacy “lock-in” procedures consistent with MassHealth’s controlled substance management program described at 130 CMR 406.442 and using the same criteria for enrollment listed on the MassHealth Drug List; d) Downtime and recovery processes; e) Electronic prescribing; and f) Claims from 340B entities as directed by EOHHS including but not limited to capturing 340B indicators and being able to process NCPDP standard transactions B1 (claim billing), B2 (claim reversal), and B3 (claim rebill).

Drug Coverage. Coverage for eligible drugs for full-time regular employees will be 100% coverage to an annual maximum benefit of $10,000 per person, and for part-time regular employees will be 80% coverage to an annual maximum benefit of $10,000 per person. A pay direct drug card or app-based digital drug card will be provided. The Employer’s obligation is limited to payment of premiums and any decisions or disputes on payment of drug coverage benefits are solely between the benefit provider and employee.