BHS PROGRAM Sample Clauses
The BHS PROGRAM clause defines the terms and conditions governing participation in a specific program, likely related to health, safety, or benefits within an organization. It typically outlines eligibility requirements, the scope of services or benefits provided, and the responsibilities of both the program administrators and participants. For example, it may specify who can enroll, what procedures must be followed, and what support or resources are available. The core function of this clause is to establish clear guidelines for program operation, ensuring that all parties understand their roles and the benefits or obligations involved.
BHS PROGRAM. RX BENEFIT DESIGN
20 1. CONTRACTOR shall reimburse only those medications that are on the BHS Program 21 formulary which shall be developed and maintained by the BHS Program. The COUNTY, through the 22 BHS Program is the payer of last resort for medically necessary medications in the treatment of mental 23 illness prescribed by Authorized BHS Program Prescribers. BHS Program maintains a formulary 24 restricted to generic formulations when they are available.
25 2. The ADMINISTRATOR or the PBM Auditor shall provide the BHS Program Formulary 26 and any modifications thereafter to CONTRACTOR. For reference only, the most current BHS 27 Program Formulary should be posted by the ADMINISTRATOR on the BHS website at: 28 ▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/bhs/about/formulary.
29 3. In order to ensure that therapeutic integrity is maintained in the face of cost considerations, 30 only generics rated as therapeutically equivalent (so-called “A” or “AB rated”), or rated equivalent to 31 the pioneer product by the FDA are covered.
32 4. ADMINISTRATOR, in rare cases, may cover a non-formulary drug when approved in 33 writing by the ADMINISTRATOR.
34 5. CONTRACTOR agrees that reimbursement of any medications authorized outside the 35 scope of the BHS Program formulary, without a proper prior authorization from the 36 ADMINISTRATOR, will result in an audit exception and funds withheld from CONTRACTOR in 37 accordance with Exhibit D to the Agreement.
1 6. CONTRACTOR agrees that all medications must be provided by the Network of 2 Pharmacies provided by the CONTRACTOR. CONTRACTOR shall provide its Pharmacy Benefits 3 Management services based on the following BHS Program guidelines. Failure to do so without proper 4 authorization from the ADMINISTRATOR will result in an audit exception and funds withheld from 5 CONTRACTOR in accordance with Exhibit C to this Agreement.
6 7. CONTRACTOR agrees that all medications available in generic formulations must be 7 prescribed as generic. If a physician prescribes a brand name product, then the pharmacy is expected to 8 substitute with a generic formulation when one is available unless a prior authorization is provided by 9 ADMINISTARTOR to the CONTRACTOR.
10 8. CONTRACTOR agrees that all medications on the formulary have a quantity limit on the 11 number of units covered in a month’s supply, and a dollar limit on the maximum payment that BHS will 12 approve. These quantity limits and maximum dollar thresholds are formulary limits on the usual ...
BHS PROGRAM. 1. Act as a liaison between the PBM and BHS Program, as necessary, for day-to-day questions, concerns, or operational issues;
2. Establish Clinical Practice Guidelines/Best Practices Development for the MRC;
3. As requested by County, personally attend meetings when deemed necessary; and
4. Periodic financial review of BHS Program expenditures, invoice analyses, and any discrepancies noted.
BHS PROGRAM. PHARMACY NETWORK MANAGEMENT
34 1. CONTRACTOR shall distribute informational materials to the Participating Pharmacies if 35 the BHS Program plan design changes or other network changes are made. Such communications shall 36 be approved by ADMINISTRATOR before distribution to the Participating Pharmacies. 37 //
1 2. CONTRACTOR shall routinely communicate, upon approval of the ADMINISTRATOR, 2 policies and procedures regarding new drugs, therapeutic substitution, utilization management, and 3 adjudication standards and practices (particularly relating to coordination of benefits) to pharmacies in 4 the network.
5 3. CONTRACTOR agrees that any communications referencing the BHS Program shall be 6 approved by the ADMINISTARTOR, including educational materials, before any materials are 7 distributed to the pharmacy network. Educational materials that may be specifically related to the BHS 8 Program include:
9 a. Formulary and preferred drug lists;
10 b. Policies & procedures related to claims submission;
11 c. New product notifications;
12 d. Communication of new clinical guidelines;
13 e. Policies & procedures related to prior authorizations;
14 f. Patient compliance reminders;
15 g. MAC program details;
16 h. Policies & procedures related to member grievances; and
17 i. Benefits of optimizing generic drugs
18 4. CONTRACTOR shall manage Participating Pharmacy relationships, including 19 credentialing and contracting, which encompasses pharmacy program compliance, contractual disputes, 20 and re-credentialing.
21 a. CONTRACTOR may be requested by the ADMINISTRATOR to go into local areas to 22 better communicate with and educate pharmacists on issues that directly impact the BHS Clients being 23 served.
24 b. CONTRACTOR shall periodically survey pharmacies in order to better monitor the 25 satisfaction and needs of network pharmacies and shall share the results of these surveys with
BHS PROGRAM. PHARMACY NETWORK MANAGEMENT
34 1. CONTRACTOR shall distribute informational materials to the Participating Pharmacies if 35 the BHS Program plan design changes or other network changes are made. Such communications shall 36 be approved by ADMINISTRATOR before distribution to the Participating Pharmacies. 37 //
1 2. CONTRACTOR shall routinely communicate, upon approval of the ADMINISTRATOR, 2 policies and procedures regarding new drugs, therapeutic substitution, utilization management, and 3 adjudication standards and practices (particularly relating to coordination of benefits) to pharmacies in 4 the network.
5 3. CONTRACTOR agrees that any communications referencing the BHS Program shall be 6 approved by the ADMINISTARTOR, including educational materials, before any materials are 7 distributed to the pharmacy network. Educational materials that may be specifically related to the BHS 8 Program include:
9 a. Formulary and preferred drug lists;
10 b. Policies & procedures related to claims submission;
11 c. New product notifications;
12 d. Communication of new clinical guidelines;
13 e. Policies & procedures related to prior authorizations;
14 f. Patient compliance reminders;
15 g. MAC program details;
16 h. Policies & procedures related to member grievances; and
17 i. Benefits of optimizing generic drugs