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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
Fields
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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apply: <br />o Review turnaround time is dependent on prescriber activity and whether additional information <br />is required. If additional information is required, the reviewer will attempt to contact physician at <br />least once daily for three days; direct contact with the prescriber will discontinue after the third <br />day. The 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 <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 />o If denied, an appeal process is available. <br />■ If elected, PBM's Manufacturer Assistance Program for Specialty Medications ("MAP"), consists of 1 <br />or 2 components when available, dependent on the specific plan design: (1) Accumulator Protection using <br />Manufacturer Copay assistance dollars to help lower member out-of-pocket costs and client costs where <br />funds are not applied to member deductible and member out-of-pocket maximum totals; and (2) <br />Accumulator Protection Plus Variable Cost -Share, where plan changes can maximize available assistance <br />funds to offset plan costs and cover the members' cost -share but does not apply to their deductible and out- <br />of-pocket 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 assistance <br />funds from manufacturers. Requires exclusive specialty pharmacy relationship. <br />o If elected, the SaveOnSP program is a benefit design change implemented by PBM in conjunction <br />with a third -party vendor, SaveOnSP. Within the SaveOnSP program, certain specialty medications <br />are classified as non-essential health benefits. This means that any funds spent on these drugs no longer <br />apply to the members' accumulators. In addition, the targeted drugs are assigned higher copays. In all <br />cases, SaveonSP helps the member coordinate manufacturer -sponsored copay assistance. SaveOnSP <br />targets drugs in six of the top ten specialty categories. <br />■ If elected, PBM's Advanced Opioid ManagementsM program reaches out to physicians, pharmacists <br />and patients at key touchpoints to minimize early exposure to opioids and to prevent patients from <br />progressing to overuse and abuse. Patients will be required to start therapy with no more than a 7 -day <br />supply of short-acting medications (with certain exceptions). Member Education will start at the first fill. <br />Doctors will be notified at the point of care when specific signs of misuse and abuse are observed. <br />3. Pricina Terms. The financial terms set forth are conditioned on such exclusive arrangement and all other <br />specified conditions set forth in Exhibit A of the Agreement. Client will pay to Administrator the amounts set <br />forth below, net of applicable Copayments. The application of Brand Drug and Generic Drug pricing below <br />may be subject to certain "dispensed as written" (DAW) protocols and Client defined plan design and coverage <br />policies for adjudication and Member Copayment purposes. Sales or excise tax or other governmental <br />surcharge, if any, will be the responsibility 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 <br />MAC price, when MAC pricing is applicable). <br />■ Mail Order: Lower of (i) Plan copayments/coinsurance or (ii) discounted AWP (including MAC price, <br />when MAC pricing is applicable). <br />■ If no adjudication rates are specified herein, each claim will be adjudicated to Client at the applicable <br />ingredient cost and will be reconciled to the applicable guarantee as set forth herein. The discounted <br />ingredient cost will be the lesser of MAC (as applicable), U&C or the applicable AWP discount. Claims <br />dispensed at ESI Mail Pharmacy will be adjudicated to Client at the applicable ingredient cost and will be <br />reconciled to the applicable guarantee as set forth herein. <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND <br />CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />7 <br />
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