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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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3.2 Specialty Products <br />(a) Exclusive Care. ESI Specialty Pharmacy is the exclusive provider of Specialty Products for the <br />reimbursement rates shown on the Exclusive ESI Specialty Pharmacy Specialty Product List. Any Specialty Product <br />dispensed at a Participating Pharmacy (for example, limited distribution products not then available through ESI <br />Specialty Pharmacy or overrides) will be reimbursed at the standard Participating Pharmacy Specialty Product rates <br />shown below. Upon ESI Specialty Pharmacy acquisition of limited distribution products, Members will obtain <br />prescriptions through ESI Specialty Pharmacy. <br />(b) Pricing for ASES is as follows: <br />(i) For Specialty Products needing an additional charge to cover costs of all ASES required to <br />administer the Specialty Products, the following standard per diem and nursing fee rates <br />shall apply. Exceptions to the standard per diem and nursing rates are set forth in (ii), <br />below, which list may be updated from time to time by ESI. Pricing for home infusion <br />supplies and services provided at Participating Pharmacies (for example, limited <br />distribution products not then available through ESI Specialty Pharmacy or overrides) will <br />be pass through. <br />Standard Per Diem $65/dose <br />Standard Nursing Fee/ First 2 Hours $150 <br />Standard Nursing Hourly 1 $75 <br />(ii) Additional exceptions to AWP Discount Rates and Standard Per Diem & Nursing Fees <br />AWP <br />Brand Name Discount Per Diem <br />EPOPROSTENOL 1.0% $65/da <br />REMODULIN 5.0% $65/da <br />The AWP discount includes Phone Support Nursing, Supplies, Pump, first two training <br />visits, and Coordination of In -Person Nursing. In-home nursing that is requested/needed <br />beyond the first two training visits will be charged at a rate of $150 for the first two hours <br />and $75 for every hour after. <br />(c) Specialty Products will be excluded from the non -specialty price guarantees set forth in the <br />Agreement. In no event will the Mail Service Pharmacy or Participating Pharmacy pricing terms specified in the <br />Agreement, including, but not limited to, the annual average ingredient cost discount guarantees, apply to Specialty <br />Products. <br />(d) Unless otherwise set forth in an agreement directly between ESI Specialty Pharmacy and Client, if <br />a Specialty Product dispensed or ASES provided by ESI Specialty Pharmacy is billed to Client directly by ESI <br />Specialty Pharmacy instead of being processed through ESI and Administrator, Client agrees to timely pay ESI <br />Specialty Pharmacy for such claim pursuant to the rates above and within thirty (3 0) days of Client's, or its designee's, <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />25 <br />Ingredient Cost <br />Dispensing Fee <br />Exclusive ESI Specialty <br />See Exclusive Specialty Product List <br />$0.00 <br />Pharmac <br />Participating Pharmacy <br />Participating Pharmacy Specialty Product <br />$0.82 <br />Specialty Products <br />List <br />Lesser of AWP discount, U&C or MRA (as <br />applicable) <br />(b) Pricing for ASES is as follows: <br />(i) For Specialty Products needing an additional charge to cover costs of all ASES required to <br />administer the Specialty Products, the following standard per diem and nursing fee rates <br />shall apply. Exceptions to the standard per diem and nursing rates are set forth in (ii), <br />below, which list may be updated from time to time by ESI. Pricing for home infusion <br />supplies and services provided at Participating Pharmacies (for example, limited <br />distribution products not then available through ESI Specialty Pharmacy or overrides) will <br />be pass through. <br />Standard Per Diem $65/dose <br />Standard Nursing Fee/ First 2 Hours $150 <br />Standard Nursing Hourly 1 $75 <br />(ii) Additional exceptions to AWP Discount Rates and Standard Per Diem & Nursing Fees <br />AWP <br />Brand Name Discount Per Diem <br />EPOPROSTENOL 1.0% $65/da <br />REMODULIN 5.0% $65/da <br />The AWP discount includes Phone Support Nursing, Supplies, Pump, first two training <br />visits, and Coordination of In -Person Nursing. In-home nursing that is requested/needed <br />beyond the first two training visits will be charged at a rate of $150 for the first two hours <br />and $75 for every hour after. <br />(c) Specialty Products will be excluded from the non -specialty price guarantees set forth in the <br />Agreement. In no event will the Mail Service Pharmacy or Participating Pharmacy pricing terms specified in the <br />Agreement, including, but not limited to, the annual average ingredient cost discount guarantees, apply to Specialty <br />Products. <br />(d) Unless otherwise set forth in an agreement directly between ESI Specialty Pharmacy and Client, if <br />a Specialty Product dispensed or ASES provided by ESI Specialty Pharmacy is billed to Client directly by ESI <br />Specialty Pharmacy instead of being processed through ESI and Administrator, Client agrees to timely pay ESI <br />Specialty Pharmacy for such claim pursuant to the rates above and within thirty (3 0) days of Client's, or its designee's, <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />25 <br />
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