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2018-015A1
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Last modified
12/21/2020 11:37:35 AM
Creation date
5/9/2018 1:10:52 PM
Metadata
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Template:
Official Documents
Official Document Type
Agreement
Approved Date
01/23/2018
Control Number
2018-015A1
Agenda Item Number
12.D.1.
Entity Name
RxBenefits
Subject
Administrative Services Agreement for Prescription Benefits
Alternate Name
Health Insurance Drug Benefits
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Pharmacies (retail), Mail Service Pharmacy and ESI Specialty Pharmacy. AWP used to calculate the <br />Prescription Drug Claim is the current, post -settlement AWP. If the Pricing Source discontinues the reporting <br />of AWP or materially changes the manner in which AWP is calculated, then ESI reserves the right to make <br />an equitable adjustment as necessary to maintain the parties' relative economics and the pricing intent of this <br />Agreement. <br />'Brand/Generic Algorithm" or "BGA" means ESI's standard and proprietary brand/generic algorithm <br />utilized by ESI, a copy of which may be made available for review by Client upon request. The purposes of <br />the algorithm are to utilize a comprehensive and logical algorithm to determine the brand or generic status of <br />products in the ESI master drug file using a combination of industry standard attributes, to stabilize products <br />"flipping" between brand and generic status as may be the case when a single indicator is used from industry <br />pricing sources, and to reduce Client, Member and provider confusion due to fluctuations in brand/generic <br />status. <br />"Brand Drug' means a prescription drug identified as such in ESI's master drug file using indicators from a <br />master drug file using indicators from Medispan on their provided (M,N,O,Y) codes. The multisource code <br />field in Medi -Span contains an "M" (co -branded product), "O" (originator brand), or an "N" (single source <br />brand); on the basis of a standard Brand/Generic Algorithm utilized by ESI across all <br />clients. Notwithstanding the foregoing, certain prescription drug medications that are licensed and then <br />currently marketed as brand name drugs, where there exists at least one (1) competing prescription <br />medication that is a generic equivalent and interchangeable with the marketed brand name drug, may process <br />as "Generic Drugs" for Prescription Drug Claim adjudication and Member Copayment purposes. <br />"Business Days" or "business days" means all days except Saturdays, Sundays, and federal holidays. All <br />references to "day(s)" are to calendar days unless "business day" is specified. <br />"Contract Year" means the full twelve (12) month period commencing on the Effective Date and each full <br />consecutive twelve (12) month period thereafter that this Agreement remains in effect. <br />"Copayment" means that portion of the charge for each Covered Drug dispensed to the Member that is the <br />responsibility of the Member (e.g., copayment, coinsurance and/or deductible) as indicated on the Set -Up <br />Forms. <br />"Cost Share" means the amount which a Member is required to pay for a prescription or authorized refill in <br />accordance with the Plan Design, which may be a deductible, a percentage of the prescription price, a fixed <br />amount and/or other charge or penalty. <br />"Covered Drug(s)" means those prescription drugs, supplies, Specialty Products (if selected on the Set -Up <br />Forms) and other items that are covered under the Prescription Drug Program, each as indicated on the Set - <br />Up Forms. <br />"Dispensing Fee" means the amount payable by Client as a dispensing fee per prescription or authorized <br />refill to a Member as set forth on Exhibit A to this Agreement. <br />"Eligibility Files" means the list submitted by Client to Administrator in reasonably acceptable electronic <br />format indicating persons eligible for drug benefit coverage services under the Client's Plan. <br />"ERISA" means the Employee Retirement Income Security Act of 1974, as amended, and the regulations <br />promulgated thereunder. <br />"ESI National Plus Network" means ESI's broadest Participating Pharmacy network. I <br />1 The ESI National Plus Network was historically referred to as the "BN50 Network" in ESI's network provider agreements with <br />Participating Pharmacies, and is subject to future name change. <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />
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