Pharmacy Benefit Manager (PBM. The MCO must use a PBM to process prescription claims. The PBM must pay claims in accordance with §843.339 of the Texas Insurance Code. This law requires PBMs to pay clean claims: (1) submitted electronically no later than 18 days after adjudication, and (2) not electronically submitted no later than 21 days after adjudication. The MCO must identify the proposed PBM and the ownership of the proposed PBM. If the PBM is owned wholly or in part by a retail pharmacy provider, chain drug store or pharmaceutical manufacturer, the MCO will submit a written description of the assurances and procedures that must be put in place under the proposed PBM Subcontract, such as an independent audit, to ensure no conflicts of interest exist and ensure the confidentiality of proprietary information. The MCO must provide a plan documenting how it will monitor such Subcontractors. These assurances and procedures must be submitted for HHSC’s review during Readiness Review (see Section 7, “Transition Phase Requirements”) then prior to initiating any PBM Subcontract after the Operational Start Date.
Pharmacy Benefit Manager (PBM an entity with which the Company contracts for the provision of administrative, utilization review and network services for the covered drug and supplies under this Program.
Pharmacy Benefit Manager (PBM. The vendor responsible for administering the Plan’s outpatient prescription drug program. The PBM provides a retail pharmacy network, mail order pharmacy, specialty pharmacy services, and coverage management programs.
Pharmacy Benefit Manager (PBM. The Contractor may use a PBM to process prescription claims only if the PBM Subcontract has received advance written approval by the Department. The Contractor must indicate the intent to use a PBM, identify the proposed PBM Subcontract and the ownership of the proposed PBM subcontractor. If the PBM is owned wholly or in part by a retail pharmacy Provider, chain drug store or pharmaceutical manufacturer, the Contractor will submit a written description of the assurances and procedures that shall be put in place under the proposed PBM Subcontract, such as an independent audit, to assure confidentiality of proprietary information. These assurances and procedures must be submitted and receive advance written approval by the Department prior to initiating the PBM Subcontract. The Department will allow the continued operation of pre-existing PBM subcontracts while the Department is reviewing such pre-existing contracts.
Pharmacy Benefit Manager (PBM. The CHC-MCO may use a PBM to process prescription Claims only if the PBM Subcontract complies with the provisions in Section XII,Subcontractual Relationships, and has received advance written approval by the Department. The standards for Network composition and adequacy for pharmacy services includes the requirements for any willing pharmacy as described above. The CHC-MCO must indicate the intent to use a PBM, identify the proposed PBM Subcontract and the ownership of the proposed PBM subcontractor. If the PBM is owned wholly or in part by a CHC-MCO, retail pharmacy Provider, chain drug store or pharmaceutical manufacturer, the CHC-MCO must submit a written description of the assurances and procedures that will be put in place under the proposed PBM Subcontract, such as an independent audit, to assure confidentiality of proprietary information. These assurances and procedures must be submitted and receive advance written approval by the Department prior to initiating the PBM Subcontract. The Department will allow the continued operation of existing PBM Subcontracts while the Department is reviewing new contracts.
Pharmacy Benefit Manager (PBM. The Contractor shall use a PBM to process prescription Claims online through a real-time, rules-based POS Claims processing system. The Contractor shall ensure that the PBM is directly available to the Agency staff. The Contractor must utilize a pass-through pricing model which means there is no difference in the PBM to pharmacy net payment amounts and MCO to PBM reported payment amounts. No additional direct or indirect remuneration fees or any membership fees or the like may be imposed on a pharmacy as a condition of Claims payment or network inclusion. No additional retrospective remuneration models including fees related to brand or generic effective rates shall be permitted. However, nothing shall preclude the reprocessing of Claims due to Claims adjudication errors of the Contractor or its agent.
