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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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Implementation Package and Member Communicatio <br />• New Member packets (includes two standard resin ID <br />Implementation support <br />cards) <br />• Member replacement cards printed via web (For hard - <br />co cards charges are vassed throu from the PB <br />No Charge <br />Concurrent Drug Utilization Review (DUR) <br />Overrides <br />a. Sponsor -requested overrides <br />b. Lost/stolen overrides <br />c. Vacation supplies <br />2.2 Administrator Clinical Programs <br />If elected, the Low Clinical Value ("LCV") exclusion option prevents unnecessary spending by removing <br />LCV medications from the formulary without impact to client rebates while providing equal or more <br />effective medicines at a lower cost. LCV medications are drugs that treat common conditions that do not <br />provide any additional or superior therapeutic value when compared to currently existing therapies already <br />in the marketplace. These medications are excluded in addition to any products that would normally be <br />excluded by PBM Formulary. This exclusion occurs without affecting rebate minimum guarantees or <br />contracted discount rates. Administrator reserves the right to amend, from time to time, the list of low <br />clinical value medications. The list of low clinical value medications may be updated quarterly. Client may <br />request a current list of LCV medications. <br />• If elected, Administrator's High Dollar Claim Review program ("HDCR"), will provide Client with <br />umbrella protection against high-cost prescription claims for approved formulary drugs. Prescription <br />claims over the threshold dollar amount are flagged prior to payment and reviewed for clinical <br />appropriateness. This additional level of clinical oversight protects against unnecessary spending, saving <br />clients money and providing improved visibility into claim reviews, decision processes, and cost savings. <br />The following may apply: <br />o RxBenefits manages the clinical review process for high dollar claims, providing oversight of the <br />process. We communicate trends and savings results to clients through detailed reporting and <br />analytics; <br />o Review turnaround time is dependent on prescriber activity and whether additional information is <br />required. If additional information is required, the reviewer will attempt to contact physician at least <br />once daily for three days; direct contact with the prescriber will discontinue after the third day. The <br />majority of reviews are completed with a disposition within 24 to 72 hours; <br />o Following a clinical review, one of four actions will occur: the medication is approved, the medication <br />claim is denied, the doctor may decide to withdraw and prescribe a different medication, or the <br />reviewer can dismiss the claim due to lack of communication from the prescriber; or <br />o If denied, an appeal process is available. <br />Foundational Utilization Management UM is a bundling of evidence -based clinical programs commonly <br />used to provide appropriate clinical oversight of prescription drug claims. UM ensures the correct clinical <br />evaluation processes are in place. Appropriate QL promotes FDA -approved dispensing guidelines by <br />ensuring appropriate quantities are dispense. ST ensures the most clinically appropriate item is used first <br />as part of adhering to accepted guidelines. When faced with two similar agents, the lowest cost option is <br />promoted first. PA ensure FDA -approved guidelines with respect to indications are being met. Utilizing <br />the PBM or customized criteria, RxBenefits has carved out the QL/ST exception review process as well as <br />all specialty and non -specialty PA reviews to be independently reviewed and documented utilizing a <br />documentation system that allows for ease of auditing through increased visibility of clinical decisions. <br />This component requires that a client elect a standard Utilization Management Programs promoted by <br />Administrator. NOTE: Must have HDCR component in place to elect this component. The following may <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND <br />CONSTITUTES TRADE SECRETS OF ESI AND RXBENEF I`S <br />6 <br />
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