Common use of Rx Benefit Design Clause in Contracts

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. Only authorized prescribers prescriptions will be covered by this medication benefit for BHS.

Rx Benefit Design. BHS Program 1. Contractor shall reimburse only those medications that are on the BHS formularyformulary which shall be developed and maintained by the BHS Program. The County, through 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 providerBHS Program Prescribers. BHS Program maintains a formulary restricted to generic formulations when they are available. a. The BHS Program or its PBM Auditor shall provide the BHS Formulary and any modifications thereafter to Contractor. GenericsFor reference only, whether they are available from one or more manufacturers, must the most current BHs Formulary should be covered posted by Contractor on the restrictive list. The formulary is posted BHS Program 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). ▇ b. 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. c. The BHS Program, in rare cases, may cover a non-formulary drug when approved in writing by the BHS Medical Director or designee(s). d. Contractor agrees that reimbursement of any medications authorized outside the scope of the formulary, without a proper prior authorization from the BHS Program, will result in an audit exception and funds withheld from Contractor in accordance with Attachment B to this Contract. 2. All medications must be obtained through Contractor’s network of Participating 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 ContractorContractor in accordance with Attachment B to this Contract. 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 BHS 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 3045-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. d. The BHS Program has engaged a third-party PAP Manager to aid in obtaining PAP eligibility for certain BHS Clients. As a result, these clients may need short-term prescription fills until such time that the PAP is approved and effective. 3. Only authorized prescribers prescriptions will be covered by this medication benefit for BHS.. The list of authorized prescribers shall be provided to Contractor by the BHS Program Manager..