Network Drug Pricing Guarantee
Network Drug Pricing Guarantees - Pharmacy Reimbursement Rates
Retail Pharmacy Network Drug Pricing Guarantees and Conditions. The Net Effective Reimbursement Rates for
network retail pharmacies will be subject to the following annual "Retail Network Guarantees":
|. Brand Discount Off AWP: 14.50%
2. Brand Dispensing Fee: $1.40
3. Generic Discount Off AWP: 70.0%
4. Generic Dispensing Fee: $1.40
The Retail Pharmacy Network Guarantees shall be subject to the following conditions:
(1) The following Claims are excluded from the Retail Network Guarantees: (i) prescriptions filled in Alaska, Hawaii,
Puerto Rico; (ii) prescriptions filled in any state which imposes some form of "Most Favored Nations? limitations on
pharmacy reimbursement; (iii) OTC Products, supplies, vaccines, member-submitted Claims, subrogation Claims and
in-house Or 340b pharmacy.
(2) Single Source Generics shall be included in the Brand Discount and Brand Dispensing Fee guarantees rather
than the Generic Discount and Generic Dispensing Fee guarantees.
(3) The Retail Network Guarantees shall be calculated on an aggregate basis, not a per Claim basis..
(4) For purposes of calculating the Retail Network Guarantee payment, if any, deficits in any of the four Retail
Network Guarantees shall be aggregated and reduced by surpluses in any of the Retail Network Guarantees, or any
surpluses in any Mail Service Network Guarantee.
Mail Service Pharmacy Network Drug Pricing Guarantees and Conditions. The Net Effective Reimbursement Rates
for mail service pharmacy will be subject to the following annual "Mail Service Network Guarantees":
1. Brand Discount Off AWP: 24.0%
2. Brand Dispensing Fee: $0.00
3 Generic Discount Off AWP: 75.0%
4. Generic Dispensing Fee: $0.00
* Single Source Generics shall be included in the Brand Discount and Brand Dispensing Fee guarantees rather than
the Generic Discount and Generic Dispensing Fee guarantees.
* The mail service pharmacy network guarantees above are for a 60 day supply or greater. Mail service pharmacy
Claims for less than a 60 day supply are subject to the following guarantees:
1. Brand Discount Off AWP: 24.0%
2. Brand Dispensing Fee: $1.40
3 Generic Discount Off AWP: 75.0%
4. Generic Dispensing Fee: $1.40
The Mail Service Network Guarantees shall be subject to the following conditions:
(1) Specialty Drugs are excluded from the Mail Service Network Guarantees.
(2) The Mail Service Network Guarantees shall be calculated on an aggregate basis, not a per Claim basis.
(3) For purposes of calculating the Mail Service Network Guarantee payment, if any, deficits in any of the Mail
Service Network Guarantees shall be aggregated and reduced by surpluses in any of the Mail Service Network
Guarantees or any surpluses in any Retail Network Guarantees.
Settlement of the Retail Network Guarantees and the Mail Service Network Guarantees for an Agreement Period
shall occur within 90 days after the Agreement Period. The Net Effective Reimbursement Rate for retail and mail
service pharmacy Claims subject to the guarantee shall be compared with the Retail Network Guarantee and Mail
Service Network Guarantee amounts. If the total actual guarantee amount exceeds the applicable Net Effective
Reimbursement Rate, Anthem will credit the amount of the excess to Employer within 30 days of the calculation.
Enterprise Administrative Services Agreement — October 2012 Master Template 34
City of Nashua 06/17/2013
