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2020-241A
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2020-241A
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Last modified
3/5/2021 2:03:08 PM
Creation date
12/7/2020 1:21:53 PM
Metadata
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Template:
Official Documents
Official Document Type
Addendum
Approved Date
11/17/2020
Control Number
2020-241A
Agenda Item Number
8.H.
Entity Name
RxBenefits, Inc. f/k/a Prescription Benefits, Inc.
Subject
Addendum to administrative services agreement (originals w/ Suzanne Boyll)
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documentation system that allows for ease of auditing through increased visibility of clinical <br />decisions. This component requires that a client elect a standard Utilization Management <br />Programs promoted by Administrator. NOTE: Must have HDCR component in place to elect <br />this component. The following may apply. <br />■ Review turnaround time is dependent on prescriber activity and whether additional <br />information is required. If additional information is required, the reviewer will attempt to <br />contact physician at least once daily for three days; direct contact with the prescriber will <br />discontinue after the third day. The majority of reviews are completed with a disposition <br />within 24 to 72 hours; <br />■ Following a clinical review, one of four actions will occur: the medication is approved, the <br />medication claim is denied, the doctor may decide to withdraw and prescribe a different <br />medication, or the reviewer can dismiss the claim due to lack of communication from the <br />prescriber; or <br />■ If denied, an appeal process is available. <br />■ If elected, PBM's Manufacturer Assistance Program for Specialty Medications <br />consists of 1 or 2 components when available, dependent on the specific plan design: (1) <br />Accumulator Protection using Manufacturer Copay assistance dollars to help lower member <br />out-of-pocket costs and client costs where funds are not applied to member deductible and <br />member out-of-pocket maximum totals; and (2) Accumulator Protection Plus Variable Cost - <br />Share, where plan changes can maximize available assistance funds to offset plan costs and <br />cover the members' cost -share but does not apply to their deductible and out-of-pocket <br />maximum, yielding high savings potential, or Therapeutic Interchange Programs where the <br />specialty pharmacy will move members to preferred agents in order to allow the usage of copay <br />assistance fiords from manufacturers. Requires exclusive specialty pharmacy relationship. <br />o If elected, the SaveOnSP program is a benefit design change implemented by PBM in <br />conjunction with a third -party vendor, SaveOnSP. Within the SaveOnSP program, certain <br />specialty medications are classified as non-essential health benefits. This means that any <br />funds spent on these drugs no longer apply to the members' accumulators. In addition, the <br />targeted drugs are assigned higher copays. In all cases, SaveonSP helps the member <br />coordinate manufacturer -sponsored copay assistance. SaveOnSP targets drugs in six of the <br />top ten specialty categories. <br />■ If elected, PBM's Advanced Opioid Managements' program reaches out to physicians, <br />pharmacists and patients at key touchpoints to minimize early exposure to opioids and to <br />prevent patients from progressing to overuse and abuse. Patients will be required to start therapy <br />with no more than a 7 -day supply of short-acting medications (with certain exceptions). <br />Member Education will start at the first fill. Doctors will be notified at the point of care when <br />specific signs of misuse and abuse are observed. <br />3. Pricin . The financial terms set forth are conditioned on such exclusive arrangement and all other specified <br />conditions set forth in Exhibit A of the Agreement. Client will pay to Administrator the amounts set forth below, net <br />of applicable Copayments. The application of Brand Drug and Generic Drug pricing below may be subject to certain <br />"dispensed as written" (DAW) protocols and Client defined plan design and coverage policies for adjudication and <br />Member Copayment purposes. Sales or excise tax or other governmental surcharge, if any, will be the responsibility <br />of Client. <br />Members will always pay based on the logic below: <br />Retail: Lowest of (i) the U&C price, (ii) Plan copayments/coinsurance, or (iii) discounted AWP (including MAC <br />price, when MAC pricing is applicable). <br />Mail Order: Lower of (i) Plan copayments/coinsurance or (ii) discounted AWP (including MAC price, when <br />MAC pricing is applicable). <br />
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