Common use of BHS PROGRAM Clause in Contracts

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 dosage 13 and expense for each medication. Prescriptions for quantities in excess of the quantity limits or drug 14 costs in excess of the maximum dollar threshold require a prior authorization. 15 9. ADMINISTRATOR typically covers only a 45-day supply of medication at a time.