Common use of Drug Coverage Clause in Contracts

Drug Coverage. Prescription drugs, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Care Connect 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 develop an escalation process for specified unique review processes and requests submitted by State or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall ensure that, at all times during the term of this Contract, its pharmacy benefit fully complies with applicable provisions of IC 12-15-35 and IC 12-15-35.5. 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, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Care Connect 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. 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 develop an escalation process for specified unique review processes and requests submitted by State or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall always ensure that, at all times during the term of this Contractcontract, its pharmacy benefit fully complies with applicable provisions of law including IC 12-15-35 and 35, IC 12-15-35.535.5 and IC 27-1-24.5. 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: 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, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Care Connect Healthwise program to be covered by the Contractor. Per 21 § CFR 203.3203.3(y), 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 develop an escalation process for specified unique review processes and requests submitted by State or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall always ensure that, at all times during the term of this Contractcontract, its pharmacy benefit fully complies with applicable provisions of law including IC 12-15-35 and IC 12-15-15- 35.5. 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: 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. A contract holder may one time in a calendar year and not earlier than six months following a previously requested audit, request an audit of compliance with the Contract. If requested by the contract holder, the audit shall include all requirements outlined in IC 27-1-24.5-25. However, in instances where the contract holder or the State Medicaid Agency receives a complaint of Medicaid Fraud or abuse from any source or identifies any questionable practices, a preliminary investigation, which may include an audit, will be conducted regardless of any prior audit pursuant to 42 CFR 455.14.

Drug Coverage. Prescription drugsdrugs including injections and infusions, certain over-the-counter drugs, pharmacy supplements, supplements and other specified products are benefits under the Hoosier Care Connect PathWays 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 support FSSA in promptly responding to public and legislative inquiries involving the design and management of the Contractor’s pharmacy benefit. If the Contractor elects to subcontract with a PBM, the Contractor shall ensure compliance with all subcontracting requirements outlined in Section 2.9, including but not limited to conducting regular audits and monitoring of the subcontractor’s data and performance, as well as requiring their PBM to conduct regular audits of their pharmacy provider networks. Pursuant to 405 IAC 1-14.6-10, all over-the-counter, legend and non-legend drugs shall not be included in the established rate for long term care facilities and will be reimbursed separately by the pharmacy benefit. Physician-administered drugs will also be covered under the pharmacy benefit. Covered drugs may be subject to utilization management that is no stricter than Fee for Service in amount, duration and scope. The Contractor shall not be responsible for member pharmacy claims incurred prior to the effective date of this contract. The Contractor shall develop an escalation process for specified unique review processes and requests submitted by State state or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall ensure that, at all times during the term of this Contract, its pharmacy benefit fully complies with applicable provisions of IC 12-15-35 and IC 12-15-35.5. 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, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Care Connect Healthwise program to be covered by the 2 For CHIP, coverage of treatment services is limited to the Package C benefit package coverage limitations. 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 develop an escalation process for specified unique review processes and requests submitted by State or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall always ensure that, at all times during the term of this Contractcontract, its pharmacy benefit fully complies with applicable provisions of law including IC 12-15-35 and IC 12-15-35.5. 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: 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, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Care Connect Healthwise program to be covered by the Contractor. Per 21 § CFR 203.3203.3(y), 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 develop an escalation process for specified unique review processes and requests submitted by State or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall always ensure that, at all times during the term of this Contractcontract, its pharmacy benefit fully complies with applicable provisions of law including IC 12-15-35 and IC 12-15-15- 35.5. 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: 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; EXHIBIT 1. C SCOPE OF WORK 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. A contract holder may one time in a calendar year and not earlier than six months following a previously requested audit, request an audit of compliance with the Contract. If requested by the contract holder, the audit shall include all requirements outlined in IC 27-1-24.5-25. However, in instances where the contract holder or the State Medicaid Agency receives a complaint of Medicaid Fraud or abuse from any source or identifies any questionable practices, a preliminary investigation, which may include an audit, will be conducted regardless of any prior audit pursuant to 42 CFR 455.14.

Drug Coverage. Prescription drugs, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Care Connect 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. 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 develop an escalation process for specified unique review processes and requests submitted by State or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall always ensure that, at all times during the term of this Contractcontract, its pharmacy benefit fully complies with applicable provisions of law including IC 12-15-35 and IC 12-15-35.5. 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: 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, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Care Connect 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 pharmaceut ical 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 develop an escalation process for specified unique review processes and requests submitted by State or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-non- IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-non- IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall ensure that, at all times during the term of this Contract, its pharmacy benefit fully complies with applicable provisions of IC 12-15-35 and IC 12-15-15- 35.5. 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, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Care Connect 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 develop an escalation process for specified unique review processes and requests submitted by State or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-non- IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-non- IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall ensure that, at all times during the term of this Contract, its pharmacy benefit fully complies with applicable provisions of IC 12-15-35 and IC 12-15-35.5. 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, certain over-the-counter drugs, pharmacy supplements, and other specified products are benefits under the Hoosier Care Connect 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 develop an escalation process for specified unique review processes and requests submitted by State or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-non- IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-non- IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall ensure that, at all times during the term of this Contract, its pharmacy benefit fully complies with applicable provisions of IC 12-15-35 and IC 12-15-15- 35.5. 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; EXHIBIT 1. E SCOPE OF WORK 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 drugsdrugs including injections and infusions, certain over-the-counter drugs, pharmacy supplements, supplements and other specified products are benefits under the Hoosier Care Connect PathWays 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 support FSSA in promptly responding to public and legislat ive inquiries involving the design and management of the Contractor’s pharmacy benefit. If the Contractor elects to subcontract with a PBM, the Contractor shall ensure compliance with all subcontracting requirements outlined in Section 2.9, including but not limited to conducting regular audits and monitoring of the subcontractor’s data and performance, as well as requiring their PBM to conduct regular audits of their pharmacy provider networks. Pursuant to 405 IAC 1-14.6-10, all over-the-counter, legend and non-legend drugs shall not be included in the established rate for long term care facilities and will be reimbursed separately by the pharmacy benefit. Physician-administered drugs will also be covered under the pharmacy benefit. Covered drugs may be subject to utilization management that is no stricter than Fee for Service in amount, duration and scope. The Contractor shall not be responsible for member pharmacy claims incurred prior to the effective date of this contract. The Contractor shall develop an escalation process for specified unique review processes and requests submitted by State state or federal legislators, the Governor, the Secretary, news media and/or of a controversial nature. The Contractor shall assure that all claims (including emergency claims) from a non-IHCP pharmacy will reject. In addition, all claims (except emergency claims) from a non-IHCP prescribing provider will reject. The Contractor shall provide for ninety (90) days of continuity of care for all pre-existing drug regimens for all new members. This will allow time for the PBM to work with the prescribing provider to negotiate future drug regimens. The Contractor shall assure proper and complete PBM agent training. The Contractor shall ensure that, at all times during the term of this Contract, its pharmacy benefit fully complies with applicable provisions of IC 12-15-35 and IC 12-15-35.5. 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.