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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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2.2 Administrator Clinical Programs <br />■ If elected, the Low Clinical Value ("LCV") exclusion option prevents unnecessary spending by <br />removing LCV medications from the formulary without impact to client rebates while providing equal <br />or more effective medicines at a lower cost. LCV medications are drugs that treat common conditions <br />that do not provide any additional or superior therapeutic value when compared to currently existing <br />therapies already in the marketplace. These medications are excluded in addition to any products that <br />would normally be excluded by PBM Formulary. This exclusion occurs without affecting rebate <br />minimum guarantees or contracted discount rates. Administrator reserves the right to amend, from time <br />to time, the list of low clinical value medications. The list of low clinical value medications may be <br />updated quarterly. Client may 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 <br />medication claim is denied, the doctor may decide to withdraw and prescribe a different medication, <br />or the 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 <br />commonly used to provide appropriate clinical oversight of prescription drug claims. UM ensures the <br />correct clinical evaluation processes are in place. Appropriate QL promotes FDA -approved dispensing <br />guidelines by ensuring appropriate quantities are dispense. ST ensures the most clinically appropriate <br />item is used first as part of adhering to accepted guidelines. When faced with two similar agents, the <br />lowest cost option is promoted first. PA ensure FDA -approved guidelines with respect to indications are <br />being met. Utilizing the PBM or customized criteria, RxBenefits has carved out the QLST exception <br />review process as well as all specialty and non -specialty PA reviews to be independently reviewed and <br />documented utilizing a documentation system that allows for ease of auditing through increased visibility <br />of clinical 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 this <br />component. The following may apply: <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 <br />medication claim is denied, the doctor may decide to withdraw and prescribe a different medication, <br />or the reviewer can dismiss the claim due to lack of communication from the prescriber; or <br />o If denied, an appeal process is available. <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />6 <br />
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