Pharmacy Management. Activities designed to monitor and oversee the utilization of medications, prescribed and over-the-counter, by both the Member and the Provider, to improve the cost/benefit of the use of pharmaceuticals. Policies: The general principles by which SCDHHS is guided in its management of the Title XIX program, as further defined by SCDHHS promulgations and by state and federal rules and regulations.
Pharmacy Management. Claim Administrator has contracted with Prime Therapeutics LLC (Prime) and/or other pharmacy benefit manager(s), mail order pharmacies, specialty pharmacies or other pharmacies to furnish certain pharmacy benefit management and other prescription drug benefit programs, including Rebate management and fee schedule management, including but not limited to MAC List management. Other services Prime will provide may include certain account management, clinical management, Drug List management, and Utilization Management services as set forth in the agreement between Prime and Claim Administrator. Claim Administrator reserves the right to contract with other pharmacy benefit managers and pharmacies directly for such services or to authorize Prime to subcontract certain services pursuant to the terms of Claim Administrator’s agreement with Prime. Please see the Agreement for additional information regarding Claim Administrator’s use of Pharmacy Benefit Managers. Employer acknowledges that Claim Administrator currently owns a significant portion of the equity of Prime. Employer further understands and agrees that fees and compensation that Prime receives related to the pharmacy benefit management program and/or the provision of pharmaceutical products and services by pharmacies may be revised. Some of these fees and compensation may be charged each time a Claim is processed (or requested to be processed) through Prime and/or each time a prescription is filled, and include, but are not limited to, administrative fees charged by Prime to Claim Administrator, administrative fees charged by Prime to pharmacies or compensation otherwise received by Prime related to network administration, and administrative fees charged by Prime to Manufacturers. Currently, none of these fees are passed on to Employer as expenses or accrue to the benefit of Employer, unless otherwise specifically set forth in the Agreement or this Exhibit.
Pharmacy Management. Contractor shall be responsible for Online Transaction Processing of claims for Covered Products submitted by Participating Pharmacies, according to the Benefit Plan coverage parameters (see Exhibit 1), Covered Individual File and Participating Prescriber File information supplied by the Board. Such Online Transaction Processing shall include eligibility and coverage determination, calculation of allowable costs and applicable Deductibles, Coinsurance or Copayments, and communication of payment disposition to Participating Pharmacies, and shall be subject to the terms and conditions of this Contract, including but not limited to the procedures set forth in Section 4.17. In addition to administering pharmacy claims, the Contractor, with the consent of the Board, shall establish the collateral procedures and services necessary to provide pharmacy benefits under the Board’s group health insurance plans in accord with the Proposal and this Contract, including enrollment and eligibility system according to Health Insurance PBM ANSI 834 Project Documents.
Pharmacy Management. 4.01 Pharmacy Management. Contractor shall be responsible for Online Transaction Processing of claims for Covered Products submitted by Participating Pharmacies, according to the benefit plan coverage parameters provided under Uniform Benefits. Covered Individual File and Participating Prescriber File information supplied by the Board. Such Online Transaction Processing shall include eligibility and coverage determination, calculation of allowable costs and applicable Deductibles, Coinsurance or Copayments, and communication of payment disposition to Participating Pharmacies, and shall be subject to the terms and conditions of this Contract, including but not limited to the procedures set forth in Section 4.17. In addition to administering pharmacy claims, the Contractor, with the consent of the Board, shall establish the collateral procedures and services necessary to provide pharmacy benefits under the Board’s group health insurance plans in accord with the Proposal and this Contract, including enrollment and eligibility system according to Health Insurance PBM ANSI 834 Project Documents.
Pharmacy Management. The PCC shall participate as directed in EOHHS’ pharmacy management initiatives, and shall refer to the MassHealth Drug List when prescribing Medically Necessary medications.
Pharmacy Management
