Common use of Pharmacy Program Claims Clause in Contracts

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.