Pharmacy Program Claims Clause Samples
Pharmacy Program Claims. (a) Employer will reimburse Claim Administrator for Claims submitted under the pharmacy program based on the pricing set forth in the BPA Addendum.
(b) Pricing Guarantees: Within two hundred ten (210) days after the end of each Guarantee Period during the initial and renewal Term, Claim Administrator will provide to Employer a report of the reconciliation of the pricing guarantees for AWP discount and dispensing fees for the Guarantee Period. Any and all pricing guarantees described in the BPA Addendum can be used to offset any and all guarantee shortfall(s). If in aggregate, actual performance is less than the guaranteed pricing, Claim Administrator will pay Employer any shortfall(s) on a dollar-for-dollar basis. Notwithstanding the foregoing, in no event will pricing guarantees, such as, but not limited to AWP discount and dispensing fees, be applicable if Employer terminates the Prescription Drug Program or this PBM Exhibit prior to the end of the Term. Compound Drug Claims, Foreign Claims, reversed claims, and out-of-network claims are excluded from the calculation of the guaranteed average annual AWP discounts shown in the BPA Addendum. Zero Balance Due Claims are included in the guaranteed average annual AWP discounts as shown in the BPA Addendum; however, the discounts are considered prior to application of Copayments/Deductibles and Coinsurance and not as a one hundred percent (100%) discount, when calculating the overall average discount. Additional pricing terms, including claims excluded from the pricing guarantees, may be set forth in the BPA Addendum. Brand Drugs: See BPA Addendum. The overall effective AWP Brand Drugs discount and Dispensing Fee are calculated in the aggregate on an annual basis and include all Covered Brand Drug Claims submitted by Network Participants under the pharmacy program, including only the Claims paid in accordance with 1 (a) above.
Pharmacy Program Claims i. Employer will reimburse Claim Administrator for Claims submitted under the pharmacy program based on the pricing set forth in the BPA Addendum.
ii. Payment by Employer is subject to applicable Copayment/Deductible and/or Coinsurance or other coverage features set forth in the Benefit Plan designated by Employer under the pharmacy program.
Pharmacy Program Claims. (a) Employer will reimburse Claim Administrator for Claims submitted under the pharmacy based on the pricing set forth in the BPA Addendum.
(b) Payment by Employer is subject to applicable Copayment/Deductible and/or Coinsurance or other coverage features set forth in the Benefit Plan designated by Employer under the pharmacy program. In each case, if applicable, Employer will pay Claim Administrator the price set forth in subsection (a) above, plus any Provider Taxes and any federal, state, or local sales, use or other tax or assessment related to any Prescription Drug Products and Services less the Member’s cost share as established by Employer. In no event will Employer be charged if the Member Copayment/Deductible or Coinsurance covers one hundred percent (100%) of the Covered Prescription Drug Products and Services. Member Deductible and Coinsurance will be calculated as described in the Agreement, and Member is also responsible for the applicable Copayment plus applicable taxes. Zero balance logic is not employed.
Pharmacy Program Claims i. Employer will reimburse Claim Administrator for Claims submitted under the pharmacy program at the Pass-Through Price.
ii. AWP Discount and Dispensing Fee Pricing Guarantees: Within two hundred ten (210) days after the end of each Guarantee Period during the initial and renewal Term, Claim Administrator will provide to Employer a report of the reconciliation of the pricing guarantees for AWP discount and Dispensing Fees for the Guarantee Period. Any and all AWP discount and Dispensing Fee pricing guarantees described in the BPA Addendum can be used to offset any and all AWP discount and Dispensing Fee guarantee shortfall(s), or otherwise used to offset AWP discount and Dispensing Fee guarantee shortfall(s) as described in the BPA Addendum. When appropriate and subject to and contingent on the Rebate terms set forth in the BPA Addendum, if actual performance is less than the guaranteed pricing, Claim Administrator will pay Employer any shortfall(s) on a dollar-for- dollar basis. Notwithstanding the foregoing, in no event will pricing guarantees, such as, but not limited to AWP discount and Dispensing Fees, be applicable if Employer terminates the Prescription Drug Program or this PBM Exhibit prior to the end of the Guarantee Period.