Pharmacy Benefits Manager Sample Clauses

Pharmacy Benefits Manager. The pharmacy benefits available to You under this Contract are managed by Our Pharmacy Benefits Manager (PBM). The PBM is a pharmacy benefits management company with which We contract to manage Your pharmacy benefits. The PBM has a nationwide network of retail pharmacies, a Mail Service pharmacy, and provides clinical management services. The management and other services the PBM provides include, among others, making recommendations to, and updating, the Covered Prescription Drug list (also known as a Formulary) and managing a network of retail pharmacies and, operating a Mail Service pharmacy. The PBM, in consultation with Us, also provides services to promote and enforce the appropriate use of pharmacy benefits, such as review for possible excessive use, recognized and recommended dosage regimens, Drug interactions or Drug/pregnancy concerns. You may request a copy of the Covered Prescription Drug list by calling the Customer Service telephone number on the back of Your I.D. Card. The Covered Prescription Drug list is subject to periodic review and amendment. Inclusion of a Drug or related item on the Covered Prescription Drug list is not a guarantee of Coverage. You may request a list of Pharmacies in the PBM network by calling the customer service number listed on the back of Your I.D. Card. Prescription Drugs, unless otherwise stated below, must be Medically Necessary and not Experimental/Investigative, in order to be Covered Health Services. For certain Prescription Drugs, the prescribing Physician may be asked to provide additional information before the PBM and/or the Contract can determine Medical Necessity. The Contract may, in its sole discretion, establish quantity and/or age limits for specific Prescription Drugs which the PBM will administer. Covered Health Services will be limited based on Medical Necessity, quantity and/or age limits established by the Contract, or utilization guidelines. Prior Authorization may be required for certain Prescription Drugs (or the prescribed quantity of a particular Drug). Prior Authorization helps promote appropriate utilization and enforcement of guidelines for Prescription Drug benefit Coverage. At the time You fill a prescription, the Participating Pharmacist is informed of the Prior Authorization requirement through the pharmacy’s computer system. The PBM uses pre-approved criteria, developed by Our Pharmacy and Therapeutics Committee which is reviewed and adopted by Us. We, or the PBM may contact Your ...
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Pharmacy Benefits Manager. (PBM) means the organization that manages the medication benefits that are given to Clients that qualify for medication benefits.

Related to Pharmacy Benefits Manager

  • Medical Benefits The Company shall reimburse the Employee for the cost of the Employee's group health, vision and dental plan coverage in effect until the end of the Termination Period. The Employee may use this payment, as well as any other payment made under this Section 6, for such continuation coverage or for any other purpose. To the extent the Employee pays the cost of such coverage, and the cost of such coverage is not deductible as a medical expense by the Employee, the Company shall "gross-up" the amount of such reimbursement for all taxes payable by the Employee on the amount of such reimbursement and the amount of such gross-up.

  • Covered Benefits and Services The Contractor shall provide to its Hoosier Healthwise members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered by the IHCP, and included in the Indiana Administrative Code and under the Contract with the State. A covered service is considered medically necessary if it meets the definition as set forth in 405 IAC 5-2-17. The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services:  On the basis of criteria applied under the State plan, such as medical necessity; or  For the purpose of utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.

  • Joint Benefits Committee In order to achieve benefit cost reductions, or at a minimum, cost containment, the parties agree to establish and aggressively participate in a Joint Benefits Committee. The parties agree that the Joint Benefits Committee shall explore all potential options or changes that could generate cost reductions to the Benefit Plans with the following order of priorities:

  • Member Benefits The members shall be entitled to the following benefits during the term of this Agreement, save and except as otherwise hereinafter provided:

  • IN EMPLOYMENT, SERVICES, BENEFITS AND FACILITIES Contractor and any subcontractors shall comply with all applicable federal, state, and local Anti-discrimination laws, regulations, and ordinances and shall not unlawfully discriminate, deny family care leave, harass, or allow harassment against any employee, applicant for employment, employee or agent of County, or recipient of services contemplated to be provided or provided under this Agreement, because of race, ancestry, marital status, color, religious creed, political belief, national origin, ethnic group identification, sex, sexual orientation, age (over 40), medical condition (including HIV and AIDS), or physical or mental disability. Contractor shall ensure that the evaluation and treatment of its employees and applicants for employment, the treatment of County employees and agents, and recipients of services are free from such discrimination and harassment. Contractor represents that it is in compliance with and agrees that it will continue to comply with the Americans with Disabilities Act of 1990 (42 U.S.C. § 12101 et seq.), the Fair Employment and Housing Act (Government Code §§ 12900 et seq.), and ensure a workplace free of sexual harassment pursuant to Government Code 12950 and regulations and guidelines issued pursuant thereto. Contractor agrees to compile data, maintain records and submit reports to permit effective enforcement of all applicable antidiscrimination laws and this provision. Contractor shall include this nondiscrimination provision in all subcontracts related to this Agreement and when applicable give notice of these obligations to labor organizations with which they have Agreements.

  • Program Benefits Under the Probation Status, the Participating Contractor will be eligible for all contractor incentives, its customers will have access to financing offered through the Program, and income- eligible households will be eligible to receive Program incentives.

  • Provision for Generation Compensation Grid unavailability in a contract year as defined in the PPA: (only period from 8 am to 6 pm to be counted): Generation Loss = [(Average Generation per hour during the Contract Year) × (number of hours of grid unavailability during the Contract Year)] Where, Average Generation per hour during the Contract Year (kWh) = Total generation in the Contract Year (kWh) ÷ Total hours of generation in the Contract Year. The excess generation by the SPD equal to this generation loss shall be procured by the Buying Utility at the PSA tariff so as to offset this loss in the succeeding 3 (three) Contract Years.

  • Sponsorship Benefits 3.1 INREV agrees to grant the Sponsor the above chosen and described sponsorship benefits.

  • Retiree Medical Benefits If Executive is or would become fifty-five (55) or older and Executive's age and service equal sixty-five (65) and Executive has at least five (5) years of service with the Company within two (2) years of Change in Control, Executive is eligible for retiree medical benefits (as such are determined immediately prior to Change in Control). Executive is eligible to commence receiving such retiree medical benefits based on the terms and conditions of the applicable plans in effect immediately prior to the Change in Control.

  • Health Benefits Eligibility a. The State System shall provide an eligible permanent full-time active employee with health benefits. The State System shall provide permanent part-time employees who are expected to be in an active pay status at least fifty (50%) of the time every pay period with health benefits.

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