Pharmacy Benefit. In providing the Medicaid pharmacy benefit to their members, MCPs must cover the same drugs covered by the Ohio Medicaid fee-for-service program. MCPs may establish a preferred drug list for members and providers which includes a listing of the drugs that they prefer to have prescribed. Preferred drugs requiring prior authorization approval must be clearly indicated as such. Pursuant to ORC §5111.172, ODJFS may approve MCP-specific pharmacy program utilization management strategies (see appendix G.3.a).
Pharmacy Benefit. In providing the Medicaid pharmacy benefit to their members, MCPs must cover the same drugs covered by the Ohio Medicaid fee-for-service program.
Pharmacy Benefit. The Employer shall provide an Employee Pharmacy Benefit through the applicable health insurance under this Article 12.
Pharmacy Benefit a. In providing the Medicaid pharmacy benefit to their members, MCPs must cover the same drugs covered by the FFS program, in accordance with OAC rule 5160-26-03(A) and (B). However, pursuant to ORC Section 5167.12, MCPs may, subject to ODM approval, implement strategies for the management of drug utilization. (See appendix K.2.f.i).
Pharmacy Benefit. Program For pharmacy benefit claims, Claims Administrator will pay Plan Sponsor a prescription drug rebate payment equal to a specific amount per paid brand-name prescription drug claim. Prescription drug rebates Claims Administrator receives from its pharmacy benefit administrator in connection with Claims Administrator's overall pharmacy benefit utilization may be more or less than the Plan Sponsor's rebate payment. Claims Administrator shall make the Plan Sponsor's rebate payment to the Plan Sponsor on a calendar quarterly basis unless agreed upon otherwise. The allowable charge for prescription drugs is higher than the price paid to the pharmacy benefit manager for those prescription drugs. The parties hereby agree that the difference between the allowable charge for prescription drugs and the price paid to the pharmacy benefit manager, and the prescription drug payments received by Claims Administrator from its pharmacy benefit manager, constitutes our property, and not part of the compensation payable to Plan Sponsor under this Contract, and that Claims Administrator is entitled to retain and shall retain such amounts and may apply them to the cost of its operations and the pharmacy benefit. Medical Benefit Drug Program The medical benefit drug program is separate from the pharmacy program. It includes claims for drugs delivered as part of medical services. For medical benefit drug claims, the Claims Administrator may contract with subcontractors that have rebate contracts with various manufacturers. Rebate subcontractors retain a portion of rebates collected as a rebate administration fee. The Claims Administrator retains a portion of the rebate. The Plan Sponsor’s medical benefit drug rebate payment shall be made to the Plan Sponsor on an annual basis if the rebate is $500 or more. If less than $500, the Claims Administrator will retain the medical benefit drug rebate.
Pharmacy Benefit. Determination of the pharmacy benefit design for the 50-64 Plan is the responsibility of United and ASI. United shall utilize its pharmacy management programs in the administration of the pharmacy benefit for the 50-64 Plan for the Pilot Period, including its Retail Pharmacy Network, Drug List (Formulary), Pharmacy and Therapeutics Committee and Drug Utilization programs. United contracts with a pharmacy benefit management company (“PBM”) for the purpose of administering these management programs. However, subject to input by *** Represents text deleted pursuant to a confidentiality treatment request filed with the Securities and Exchange Commission pursuant to Rule 24b-2 under the Securities Exchange Act of 1934, as amended. ASI, United retains responsibility and control of all pharmacy management program decisions. The contracted PBM shall not have the authority to implement clinical or benefit programs without United’s written consent.
Pharmacy Benefit. The health plan may limit the drugs covered through use of a list called a “formulary.” Each health plan’s formulary includes all major therapeutic classes of drugs. Drugs not in the formulary will be covered if the health plan’s medical staff determines that no formulary drugs are an acceptable medication for the patient. In addition to the formulary described above, each health plan will have the following five therapeutic classes of drugs covered under the first tier, subject to a $10 copay; inhaled short-acting beta-agonists, inhaled steroids, inhaled anticholinergic bronchodilators, beta-blockers for severe heart failure, and anti-platelet clotting inhibitors for patients after intra-arterial stent placement. The members’ copay will be $10 regardless (or independent) of the drug’s generic or name brand status. If you have a question about the pharmacy benefit, are not sure if a drug is covered, or believe a nonformulary drug should be covered, call the health plan’s customer service department. Basic Health covers drugs of all types, including prescribed creams, ointments, and injections, at the copayment levels shown. Prescriptions are not subject to the deductible and will not apply towards the annual out-of-pocket maximum. When the actual cost of the drug is less than the $10 copay, members are only responsible for the cost of the drug. Prescriptions are limited to a 30-day supply. Drugs for cosmetic purposes are excluded unless preauthorized. (See table below for more pharmacy copayment information.) Tier 1 - Copayment: $10 Tier 2 - Copayment: 50% Covered drugs: Covered drugs: 30 Basic Health 2008 Member Handbook Table of Contents Appendix A: Schedule of Benefits Generic drugs contained in the health plan’s formulary. Brand-name drugs in the health plan’s formulary. All oral contraceptives in the health plan’s formulary. Diabetic supplies, including syringes and needles, diabetic test strips, lancets, and insulin. Inhaled short-acting beta-agonists. Inhaled steroids. Inhaled anticholinergic bronchodilators. Beta-blockers for severe heart failure. Anti-platelet clotting inhibitors for patients after intra-arterial stent placement.
