Premium Rebates definition

Premium Rebates provision has been added to the “Miscellaneous Provisions” section of the Group Agreement, in accordance with the ACA. The provision clarifies the roles and responsibilities of Company and of Group in the event that a Premium rebate is required. The “Reporting Membership Changes and Retroactivity” provision under the “Miscellaneous Provisions” section of the Group Agreement has been modified. We have clarified that membership forms must be approved by Company.
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Premium Rebates means the adjustment to premiums paid by HCA to the Contractor in order to satisfy the minimum MLR requirement. If premiums paid result in an MLR of 80% then there will be Premium Rebate of 11.12% of premiums less taxes and fees so that the MLR will rise to 90%. If the Contractor owes a Premium Rebate, the Premium Rebate will be paid by the Contractor to HCA.
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Premium Rebates. The Premium formulary is OptumRx’s lead national formulary, with a limited number of exclusions that drive stronger rebates and the lowest cost to the Client. Premium PDL rebates are contingent upon: Client's adoption, without deviation, of OptumRx’s formulary and formulary exclusions, as well as any changes OptumRx makes to its formulary and formulary exclusions; and implementation of the step therapies required by OptumRx in the following therapeutic classes: Rheumatoid Arthritis, Ankylosing Spondylitis, Plaque Psoriasis, Psoriatic Arthritis, Hepatitis-C, Multiple Sclerosis, and PCSK9.  Select Base Rebates: Client's adoption, without deviation, of OptumRx’s formulary, as well as any changes OptumRx makes to its formulary; and a minimum of $10 difference in copayment, or 10 percent difference in coinsurance between preferred and non-preferred Brand Drugs.  Select Comprehensive Rebates: The Select Comprehensive formulary has an extensive list of utilization management programs, driving an improvement in rebate value as opposed to formularies with fewer formulary management requirements. Select Comprehensive rebates are contingent upon: Client's adoption, without deviation, of OptumRx’s formulary and utilization management programs, as well as any changes OptumRx makes to its formulary or utilization management programs; and a minimum of $10 difference in copayment, or 10 percent difference in coinsurance between preferred and non-preferred Brand Drugs.  Rebate claims exclude ineligible claims, such as claims with invalid service provider identification or prescription numbers; claims where, after meeting the deductible, the Member's Cost-Sharing Amount under the applicable Benefit Plan requires the Member to pay more than 50 percent of the claim; claims for devices without a Prescription Drug component; claims for re-packaged NDCs; stale dated claims over 180 days old; compounds; claims from 340B which typically receive a discount or rebate directly from Drug Manufacturers under section 340B of the Public Health Service Act, or claims from entities eligible for federal supply schedule prices (for example, Department of Veterans Affairs, U.S. Public Health Service, Department of Defense); or claims that are not for Prescription Drugs (except for insulin or diabetic supplies).  If Client makes any change to its formulary, not initiated by OptumRx, changes the Benefit Plan, or adopts any formulary or utilization management program other than one of the op...
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Examples of Premium Rebates in a sentence

  • L7.6 If applicable, the Employer shall return prior to July 30 to the Bargaining Unit the Federal Employment Premium Rebates to which the individual Bargaining Unit members are entitled for the previous twelve (12) months.

  • Premium Rebates If state or federal law requires the Health Plan to rebate Premium from this or any earlier contract year and the Health Plan rebates Premium to the Group, those responsible to represent that the Group will use that rebate for the benefit of Members, in a manner consistent with the requirements of the Public Health Service Act, the Affordable Care Act, and the obligations of a fiduciary under the Employee Retirement Income Security Act (ERISA).

  • HCA intends to reconcile the Premium Rebates relating to the MLR Incentive Threshold concurrently with the final Federal reconciliation of the MLR rebate.

  • Premium Rebates If state or federal law requires the Health Plan to rebate Premiums from this or any earlier contract year and the Health Plan rebates Premiums to the Group, those responsible to represent that the Group will use that rebate for the benefit of Members, in a manner consistent with the requirements of the Public Health Service Act, the Affordable Care Act and the obligations of a fiduciary under the Employee Retirement Income Security Act (ERISA).

  • Premium Rebates are contingent upon: County's adoption, without deviation, of Contractor’s Formulary and Formulary exclusions, as well as any changes Contractor makes to its Formulary and Formulary exclusions; and the implementation of the step therapies required by Contractor, as well as any changes Contractor makes to its Formulary and formulary exclusions; and the implementation of the step therapies required by Contractor, as well as any changes Contractor makes to its utilization management programs.