Common use of Specialty Pharmacy Clause in Contracts

Specialty Pharmacy. PBM shall provide the following services from its specialty pharmacy: (i) receive prescriptions for Specialty Drugs, as identified in the Specialty Drug List (which is a fixed list amended from time to time under rules described in Exhibit C), subject to and in accordance with the Plan Design Document. (ii) fill prescriptions, subject to the professional judgment of the dispensing pharmacist via U.S. mail or commercial carrier or facsimile machine at an address or telephone number specified by PBM from time to time; (iii) provide Members dedicated toll-free telephone access to a pharmacist and customer service representatives; (iv) provide to Participating Group promotional materials that explain to Members how to use the specialty service program, as well as any other materials Members may require to begin using the specialty program and Participating Group shall distribute such information to Members; (v) provide computerized drug interaction monitoring of Members based upon the Member profile, programs for generic substitution and therapeutic intervention, pharmaceutical cost containment services and safety edits, and subject to prescriber approval, clinical appropriateness, the terms of the Participating Group Plan and applicable law; (vi) ship all prescription orders to Members via U.S. Postal Service or other appropriate carrier to the address provided by Participating Group and/or the Member, as long as such addresses are located in the United States or location that permits delivery of prescriptions through such means; and (vii) not dispense drugs if the prescription is not accompanied by the Cost Sharing as applicable. (viii) New Specialty Drugs that fall into an existing therapeutic class will be priced at that therapeutic class rate as set forth under Exhibit C. This provision shall include any drugs that PBM deems to be a bio- similar product. (ix) A Participating Group without incurring an increase in specialty drug discount costs from PBM. Neither Client nor CCOG may contract with an additional Specialty Vendor on behalf of Participating Groups. (x) ii) Specialty Pharmacy contracted rate plus zero charge for the product or (iv) Ingredient Cost Submitted.

Specialty Pharmacy. PBM shall provide As elected by Sponsor on the following services from its specialty pharmacy:Set-Up Forms, Members may have prescriptions filled through ESI Specialty Pharmacy on an exclusive basis (i.e., “ESI Specialty Pharmacy – Exclusive Care”) or at Participating Pharmacies and through ESI Specialty Pharmacy (i.e., “ESI Specialty Pharmacy – Open Care”). Subject to applicable law, ESI and ESI Specialty Pharmacy may communicate with Members and physicians to advise Members filling Specialty Products at Participating Pharmacies of the availability of filling prescriptions through ESI Specialty Pharmacy. (i) receive prescriptions ESI will notify Sponsor and Aon ▇▇▇▇▇▇ monthly of any new Specialty Products that are introduced to the market on or after the Effective Date of this Agreement with their applicable reimbursement rates (“Notice”). Only newly FDA-approved and launched Specialty Products may be considered for Specialty Drugs, as identified in addition to the Specialty Drug Product List. Notice will be provided in advance of any modification with an explanation of the rationale for such modification. On a quarterly basis on the first business day of the first month of the quarter, ESI shall provide Aon ▇▇▇▇▇▇ and Sponsor with a revised and complete Specialty Product List noting the effective date for each modification. The parties agree as follows: (which is A) If Sponsor has expressly excluded a fixed list amended specific therapy class or product on a Set-Up Form, Specialty Products in such excluded classes will automatically be deemed excluded from time to time under rules described in Exhibit C)coverage and will reject as “NDC Not Covered” through Participating Pharmacies, Mail Service Pharmacy and ESI Specialty Pharmacy; otherwise, subject to (B) below, all other Specialty Products will be implemented as Covered Drugs at the rate specified in the applicable Specialty Product List or Notice. If Sponsor desires to cover otherwise excluded Specialty Products, Sponsor must notify ESI in writing that it desires to cover the Specialty Product before ESI will adjudicate as a Covered Drug, and if ESI receives such confirmation of coverage from Sponsor such Specialty Product will be loaded thereafter as a Covered Drug at the applicable reimbursement rate set forth in accordance with the Plan Design DocumentNotice. (B) Sponsor must notify ESI in writing if it wants to exclude the Specialty Product from coverage. The exclusion will be implemented within seven (7) business days after the date of ESI’s receipt of such notification. There will not be any retroactive denials for Prescription Drug Claims processed prior to ESI’s receipt of the rejection notice and implementation of the exclusion as provided above and Sponsor will be responsible for the payment of such Prescription Drug Claims processed prior to the rejection of coverage. (ii) fill prescriptionsFor Specialty Products filled through ESI Specialty Pharmacy only, subject to Members may receive the professional judgment of following services from ESI Specialty Pharmacy: patient intake services, pharmacy dispensing services, and depending on the dispensing pharmacist via U.S. mail particular therapy class or commercial carrier or facsimile machine at an address or telephone number specified by PBM from time to time;disease state: ASES and/or social services (patient advocacy, hardship reimbursement support, and indigent and patient assistance programs). (iii) Subject to Sponsor’s prior authorization requirements, if applicable, at the rates set forth in Exhibit B, ESI will provide or coordinate ASES for Members dedicated toll-free telephone access through ESI Specialty Pharmacy or through other specialty pharmacies or other independent third party providers of ASES when ASES is required. If ESI or ESI Specialty Pharmacy engages a third party provider of ASES, ESI or ESI Specialty Pharmacy shall contractually obligate such third party provider of ASES to a pharmacist and customer service representatives;comply with all applicable laws, including, without limitation, all applicable laws relating to professional licensure. ESI does not direct or exercise any control over any third party provider of ASES in administering Specialty Products or otherwise providing ASES. (iv) provide to Participating Group promotional materials that explain to Members how to use If Sponsor elects the specialty service programESI Specialty Pharmacy - Open Care option, as well as then any other materials Members may require to begin using the specialty program and Participating Group shall distribute such information to Members; (v) provide computerized drug interaction monitoring of Members based upon the Member profileancillary supplies, programs for generic substitution and therapeutic intervention, pharmaceutical cost containment services and safety editsequipment, and subject services provided or coordinated in connection with the dispensing of Specialty Products at Participating Pharmacies (for example, limited distribution products not then available through ESI Specialty Pharmacy or overrides) will be billed to prescriber approvalSponsor at the cost charged to ESI for such ancillary supplies, clinical appropriatenessequipment, and services provided or coordinated, unless such ancillary supplies, equipment, and services provided or coordinated are included in the terms ingredient cost of the Participating Group Plan and applicable law; (vi) ship all prescription orders to Members via U.S. Postal Service or other appropriate carrier to the address provided by Participating Group and/or the Member, as long as such addresses are located in the United States or location that permits delivery of prescriptions through such means; and (vii) not dispense drugs if the prescription is not accompanied by the Cost Sharing as applicable. (viii) New Specialty Drugs that fall into an existing therapeutic class will be priced Product. The above also applies for products dispensed at that therapeutic class rate as set forth under Exhibit C. This provision shall include any drugs that PBM deems to be a bio- similar product. (ix) A Participating Group without incurring an increase in specialty drug discount costs from PBM. Neither Client nor CCOG may contract with an additional Specialty Vendor on behalf of Participating Groups. (x) ii) Specialty Pharmacy contracted rate plus zero charge retail for the product Exclusive option that allows first fills at retail or (iv) Ingredient Cost Submittedfor products which ESI does not have access to.