Rx Benefit Design Clause Samples

Rx Benefit Design. BHS Program 1. Contractor shall reimburse only those medications that are on the BHS formulary. The BHS Program is the payer of last resort for medically necessary medications in the treatment of mental illness prescribed by psychiatrists or psychiatric nurse practitioners working for the County or a County-contracted provider. BHS Program maintains a formulary restricted to generic formulations when they are available. Generics, whether they are available from one or more manufacturers, must be covered by Contractor on the restrictive list. The formulary is posted on the BHS website at: : ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇▇▇/▇▇▇▇▇▇▇▇▇ The BHS Program, in rare cases, may cover a non-formulary drug when approved in writing by the BHS Medical Director or designee(s). In order to ensure that therapeutic integrity is maintained in the face of cost considerations, only generics rated as therapeutically equivalent (so-called “A” or “AB rated”), or rated equivalent to the pioneer product by the FDA are covered. 2. All medications must be obtained through Contractor’s network of pharmacies. Contractor shall provide its Pharmacy Benefits Manager services based on the following BHS Program guidelines. Failure to do so without proper authorization from the BHS Program will result in an audit exception and funds withheld from Contractor. a. All medications available in generic must be prescribed as generic. If a physician prescribes a brand name product, then the pharmacy is expected to substitute with a generic when one is available unless a prior authorization is provided by County to the Contractor. b. All medications on the formulary have a quantity limit on the number of units covered in a month’s supply, and a dollar limit on the maximum payment that MSI will approve. These quantity limits and maximum dollar thresholds are formulary limits on the usual dosage and expense for each medication. Prescriptions for quantities in excess of the quantity limits or drug costs in excess of the maximum dollar threshold require a prior authorization. c. BHS typically covers only a 30-day supply of medication at a time. However, appointment times vary depending on the acuity of the patient and the next availability of appointment. Accordingly, Contractor should have means to allow multiple prescriptions for one or two week’s duration of the same medication within a one month period. Similarly, Contractor should have means to allow prescriptions for five or six week’s duration. 3. ...
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Rx Benefit Design. MSI Program 1. Contractor shall reimburse only those medications that are ADAP formulary for 340B Covered Drugs and only those medications that are on the MSI formulary for non-replenished 340B Covered Drugs. All MSI formulary generics must be adjudicated as generic. The MSI Program is the payer of last resort for medically necessary medications. In order to formalize the medications covered, the MSI Program has developed an MSI formulary. This MSI formulary is restrictive in that only those medications on the formulary list are covered. Further, payments are restricted to generic formulations and/or step therapy medications when they are available. Generics, whether they are available from one or more manufacturers, must be covered by Contractor on the restrictive list. The MSI formulary is posted on the MSI website at: ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/docs/medical/msi_providers/formulary/MSI-Drug-Formulary-lists.pdf and shall be provided to Contractor at least quarterly commencing May 1, 2012. Contractor shall submit updates to the ADAP formulary to County as they occur. Exclusions from the MSI formulary include medications not listed in the MSI formulary, over-the- counter medications and specific therapeutic classifications relating to conditions outside the scope of the MSI Program. The MSI Program in rare cases may cover a non-formulary drug where one of the following conditions is present: a. All MSI formulary options have been ineffective, or b. Another non-formulary drug is less expensive, or c. There is an overwhelming case-specific need, and the diagnosis is within the scope of the MSI Program and is consistent with the prescription. In order to ensure that therapeutic integrity is maintained in the face of cost considerations, only generics rated as therapeutically equivalent (so-called ―A‖ or ―AB rated‖), or rated equivalent to the pioneer product by the FDA are covered. 2. All medications must be obtained through Contractor‘s network of pharmacies. In addition to maintaining its own formulary, medications paid for by the MSI Program are limited to those prescribed by Orange County physicians at Covered Entity locations and filled in Orange County pharmacies. Contractor shall provide its Pharmacy Benefits Manager services based on the following MSI Program guidelines. Failure to do so without proper authorization from the MSI Program will result in an audit exception and funds withheld from Contractor. a. All medications available in generic must b...
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Related to Rx Benefit Design

  • Plan Design The flexible benefits plan is a cafeteria-style benefits program wherein the County makes a contribution toward the Flexible Benefits Plan for each eligible employee to be allocated during the employee's active employment. The County contribution is distributed by the employee among the menu of benefit options listed below, the specific details and administration of which are set forth in the plan brochures: • Health insurance • County basic life and AD&D insurance • Dental insurance • Vision insurance • Supplemental life insurance • Supplemental accidental death and dismemberment insurance (AD&D) • Flexible spending accounts for pre-tax reimbursement of qualified medical and/or dependent day care expenses. Account credits must be used during the plan year in which they are earned for expenses incurred during the same plan year. • The plan may be modified upon written notice by the County. This plan includes for eligible employees pre-tax contributions for all monies paid toward health, dental, vision and/or voluntary AD&D plans.

  • Order of Benefit Determination Rules When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows:

  • Application for Benefits Requests for short-term leaves shall be in writing, upon the appropriate form prescribed and provided by the District, and shall be filed with the unit member's supervisor and the appropriate manager five (5) days in advance of the intended leave (except in emergency situations), unless otherwise stated by the provisions of the specific leave.

  • Executive Benefit Plans The Executive shall be entitled to participate in all plans or programs sponsored by the Company for employees in general, including without limitation, participation in any group health, medical reimbursement, or life insurance plans.

  • Synopsis and Benefit to ▇▇▇▇▇▇▇ County ▇▇▇▇▇▇▇ County has been working with the State of Oregon, Department of Corrections, for several years to provide correctional services for the supervision of cases resulting from Senate Bill 1145. ▇▇▇▇▇▇▇ County is assigned responsibility for all justice-involved individuals on probation, parole, post-prison supervision, and those justice-involved individuals sentenced or revoked for periods of one year or less, and who are on conditional release to the County. The State reimburses the County for expenses associated with housing and supervision of these individuals through Community Corrections Act funding, provided through this Agreement.