Benefit Management Clause Samples

Benefit Management. 4.5.1 Formulary, Plan Design, and Utilization Management 1. The State reserves the right to exclude medications on the Contractor’s formulary that are considered low-value medications (e.g., Duexis) and/or prefer medications with a lower net cost. 2. Contractor's financial bid shall include all clinical and utilization management programs such as step therapy, prior authorization, quantity limits, etc., as provided in the Solicitation. 3. Contractor shall manage prior authorization requests using State-approved criteria. 4. Contractor shall respond to prior authorization requests within forty-eight (48) hours, seven (7) days a week. 5. Contractor shall only initiate therapeutic interchanges when switching to drugs with a lower net cost (including rebates). 6. Contractor shall only initiate therapeutic interchanges on drug pairs authorized by the State. 7. Contractor shall provide the opportunity for the State to participate in patient assistance management or coordination programs. 8. Contractor shall provide a means of tracking claims using manufacturers’ or other entities’ patient assistance programs or coupons. 9. Contractor shall provide a system that adjusts Member accumulators when Members use patient assistance, coupons, or other similar manufacturer Member financial assistance programs. 10. Contractor shall not charge the State for any patient assistance, coupon, or other similar manufacturer co-pay assistance programs. 11. Contractor shall hold all negative formulary tier changes until 1/1 of the next Calendar year, unless directed otherwise by the State. 12. Contractor shall notify the State at least 90 calendar days prior to any formulary change. 13. Prior to making any modification to the formulary, Contractor shall advise the State regarding the impact on Members and whether it will impact any Rebate guarantees. 14. Contractor shall grandfather any formulary excluded drugs for up to three (3) months without any impact on financial guarantees during the initial plan year (i.e., discount and Rebate guarantees will be in effect as of the go-live date). 4.5.2 Specialty, LDD, New-to-Market 1. Contractor agrees that if a Specialty Drug package is lost, stolen, or not delivered, Contractor will not charge the Member or Plan Sponsor for such Specialty Drug. 2. Contractor agrees that Non-Specialty Drugs filled through a Specialty Pharmacy will be adjudicated and billed at Mail Order rates, and further, included with the Mail Order Network Discount guar...