Pharmacy Rebate Program Sample Clauses
Pharmacy Rebate Program. Under the provisions of Section 1927 of the Social Security Act, 42 U.S.C.A. §1396r-8, drug companies that wish to have their products covered through the Texas Medicaid Program must sign an agreement with the federal government to provide the pharmacy claims information that is necessary to return federal rebates to the state. The MCO is not authorized to negotiate rebates with drug companies for preferred pharmaceutical products. HHSC or its designee will negotiate rebate agreements. If the MCO or its PBM has an existing rebate agreement with a manufacturer, all Medicaid and CHIP outpatient drug claims, including provider-administered drugs, must be exempt from such rebate agreements. The MCO must implement a process to timely support HHSC’s Medicaid and CHIP rebate dispute resolution processes.
a. The MCO must allow HHSC or its designee to contact Network pharmacy Providers to verify information submitted on claims, and upon HHSC’s request, assist with this process.
b. The MCO must establish a single point of contact where the HHSC’s designee can send information on claims needing correction.
c. HHSC will notify the MCO of claims submitted with incorrect information. The MCO must correct this information on the next scheduled pharmacy encounter data transmission.
Pharmacy Rebate Program. The Pharmacy Rebate Program, as set forth in the Operations Manual, permits the sharing of calendar year pharmaceutical rebates (“Annual Rebates”). HMO shall multiply the Annual Rebates by an annually-determined percentage (“Rebate Percentage”) to establish the Rebate Fund. HMO shall divide the Rebate Fund by the total number of Commercial HMO Members eligible for a pharmacy benefit to determine the Rebate PEMPM. On or before December 15th of each year, HMO shall notify PPG of the Rebate Percentage. PPG is eligible for a lump sum award as determined and identified below. Such sum is payable in April following the calendar year of the Rebate Fund, beginning April 1999. PPG’s PEMPM award shall be determined by PPG’s cost performance relative to other participating physician groups. Cost performance shall be determined by the normalized pharmacy cost for each calendar year for each participating physician groups. Three performance tiers shall be established; each tier shall represent approximately one-third of the total Commercial HMO Members, provided, however, that any participating physician group with assigned Commercial HMO Members less than *** or exceeding *** annual Member months shall be excluded from the tier determination. PPG’s PEMPM award for eligible Commercial HMO Members shall be as follows based upon PPG’s tier ranking: Lowest Normalized Pharmacy Costs *** of Rebate PEMPM Middle Normalized Pharmacy Costs *** of Rebate PEMPM Highest Normalized Pharmacy Costs *** of Rebate PEMPM The age, sex and benefit plan factors shall be developed by HMO based upon actuarial assumptions consistent with existing actuarial assumptions and HMO’s utilization experience. Such factors, as updated approximately every three years to reflect changing demographic and utilization patterns, shall be forwarded to PPG and are incorporated into this Agreement by reference.