My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
2020-241A
CBCC
>
Official Documents
>
2020's
>
2020
>
2020-241A
Metadata
Thumbnails
Annotations
Entry Properties
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)
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
48
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
Administrative Services <br />Fees <br />Initial Determinations and Level One Appeals for the <br />No Charge <br />Benefit Review Program, consisting of reviews <br />$3.00 per claim <br />known as: <br />$3.00 per claim <br />Plan Design Related Requests <br />$0.32 / PMPM of Elected <br />Plan Exclusion Reviews (clinical or <br />$0.03 / PMPM of Elected <br />administrative reviews of non -Covered Drugs) <br />Copay Reviews <br />$0.10 PMPM per combined accumulator up to <br />Plan Limit Reviews (e.g. age, gender, days' <br />maximum of $0.20 PMPM for existing <br />supply limits) <br />connection with medical carrier or TPA. <br />Plan Rule/Administrative Reviews/Non-clinical <br />Fees to establish connection with new medical <br />Reviews <br />carrier or TPA are quoted upon request. <br />Clinical Benefit Reviews <br />Direct Claim Reject Reviews <br />Final and Binding Appeals — Level Two Appeals * <br />No Charge <br />and/or Urgent Appeals** <br />*Level One for clients with only one level of <br />appeal <br />20% of audit recoveries <br />** Appeals can be urgent at Level One or Level <br />Two and decisions are final and binding. <br />External Reviews by Independent Review <br />No Charge <br />-Organizations - for non -grandfathered plans <br />PBM Services <br />Fees <br />Advanced Utilization Management (AUM Bundle) <br />$0.46 / PMPM <br />Member -submitted paper claims processing fee <br />$3.00 per claim <br />Medicaid subrogation claims fee <br />$3.00 per claim <br />Opioid Program <br />$0.32 / PMPM of Elected <br />ACA Statin "Trend Management" Pro ram <br />$0.03 / PMPM of Elected <br />Combined Benefit Management <br />Services to manage combined medical -pharmacy <br />$0.10 PMPM per combined accumulator up to <br />benefits that are not a consumer -directed health <br />maximum of $0.20 PMPM for existing <br />(CDH) plan. <br />connection with medical carrier or TPA. <br />Services include ongoing management of the data <br />Fees to establish connection with new medical <br />exchange platform with the medical vendor/TPA, <br />carrier or TPA are quoted upon request. <br />production monitoring and quality control, and <br />designated operations team. Combined benefit types <br />may include deductible, out of pocket, spending <br />account and lifetime maximum. <br />Network Pharmacy Services <br />Network Pharmacy Audit Program <br />20% of audit recoveries <br />Comprehensive Consumer Driven Health (CDH) <br />Solution <br />Consumer Choice Plan - Technical <br />$0.35 PMPM <br />• Bi-directional data exchange; dedicated <br />*these charges would be in addition to any pricing <br />operations; 24-hour a day, seven -days a week <br />adjustments if greater than ten percent of Clients total <br />monitoring and quality control; performance <br />utilization for all Plans is attributable to a CDHC. <br />reporting; and analytics <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />
The URL can be used to link to this page
Your browser does not support the video tag.