Ancillary Supplies, Equipment, and Services or ASES means ancillary supplies, equipment, and services provided or coordinated by ESI Specialty Pharmacy in connection with ESI Specialty Pharmacy’s dispensing of Specialty Products. ASES may include all or some of the following: telephonic and/or in-person training, nursing/clinical services, in-home infusion and related support, patient monitoring, medication pumps, tubing, syringes, gauze pads, sharps containers, lancets, test strips, other supplies, and durable medical equipment. The aforementioned list is illustrative only (not exhaustive) and may include other supplies, equipment, and services based on the patient’s needs, prescriber instructions, payer requirements, and/or the Specialty Product manufacturer’s requirements.
Ancillary Supplies, Equipment, and Services. For Specialty Products needing an additional charge to cover costs of all ASES required to administer the Specialty Products, Administrator, ESI or ESI Specialty Pharmacy will bill at the following standard per diem and nursing fee rates set forth below, maintained and updated by ESI from time to time. If ESI elects to bill Client’s medical plan for ASES, Administrator will work with ESI to coordinate the invoicing and payment of ASES through Client’s medical plan. If Client’s medical plan will not cover the cost of ASES billed through ESI or ESI Specialty Pharmacy, Client shall be responsible for the costs of all ASES. If a Specialty Product dispensed or ASES provided by ESI Specialty Pharmacy is billed to Administrator or a Client directly by ESI Specialty Pharmacy instead of being processed through ESI, Client will timely pay Administrator, and Administrator will timely pay ESI Specialty Pharmacy for such claim pursuant to the rates below. ESI Specialty Pharmacy shall have 360 days from the date of service to submit such electronic or paper claim. Therapeutic Class Brand Name Nursing & Per Diem Immune Deficiency All Immune Deficiency Drugs requiring Per Diem $60.00 / Infusion Enzyme Deficiency All Enzyme Deficiency Drugs required Per Diem $60.00 / Infusion Miscellaneous Specialty Conditions Duopa $65.00 / Day Miscellaneous Specialty Conditions Soliris $60.00 / Infusion PAH Flolan, Veletri, Epoprostenol Sodium (generic- Flolan/Veletri), and Remodulin $65.00 / Day PAH Ventavis $65.00 / Day PAH Tyvaso $30.00 / Day Inflammatory Conditions Remicade $60.00 / Infusion Alpha 1 Deficiency All Alpha 1 Deficiency Drugs requiring Per Diem $55.00 / Infusion Nursing Rates All drugs / therapies requiring nursing $150.00 per initial visit up to two (2) hours/$75.00 per additional hour or a fraction thereof
Ancillary Supplies, Equipment, and Services. For Specialty Drugs filled through a Specialty Pharmacy only, Members may receive the following services from a Specialty Pharmacy, depending on the particular therapy class or disease state: ASES; patient intake services; pharmacy dispensing services and/or social services (patient advocacy, hardship reimbursement support, and indigent and patient assistance programs). Subject to applicable prior authorization requirements and at the rates set forth in Exhibit C (Fees and Compensation), PBM will provide or coordinate ASES for Members through Specialty Pharmacies or other Vendors of ASES when ASES is required. PBM may engage a Vendor to provide ASES. PBM does not direct or exercise any control over such Vendor in administering Specialty Drugs or otherwise providing ASES. In the event that ASES is provided or coordinated in connection with the dispensing of Specialty Drugs at Participating Pharmacies (excluding Specialty Pharmacies; e.g., limited distribution products not then available through Specialty Pharmacy or overrides), the cost, if any, may be billed to Client at the cost charged to PBM, unless such ASES provided or coordinated are included in the Ingredient Cost of the Specialty Drug.
