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A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK generate more than $250,000.00 in annual pharmacy plan spend. Clinical pharmacists reach out to Prescribers to request and review medical documentation and tackle issues such as redundant therapies, dosing errors, potential drug -on -drug interactions, and medication misuse. If HDCR is elected, Administrator's Therapeutic Interchange for High -Cost Specialty Medications ("HTI") identifies and promotes lower cost, clinically effective alternatives for certain categories of drugs. ■ The following may apply to HDCR: ■ Administrator manages the clinical review process for high dollar claims, providing oversight of the process. Administrator communicates trends and savings results to clients through detailed reporting and analytics. ■ Review turnaround time is dependent on prescriber activity and whether additional information is required. If additional information is required, the reviewer will attempt to contact physician at least once daily for three days; direct contact with the prescriber will discontinue after the third day. The majority of reviews are completed with a disposition within 24 to 72 hours. ■ Following a clinical review, one of four actions will occur: (i) the medication is approved, (ii) the medication claim is denied, (iii) the prescriber may decide to withdraw and prescribe a different medication, or (iv) the reviewer can dismiss or deny the claim due to lack of communication from the prescriber; or ■ If denied, an appeal process is available. ■ If HDCR is elected, the Administrator will also manage all other Prior Authorizations and Appeals. o Following a clinical review, one of four actions will occur: the medication is approved, the medication claim is denied, the doctor may decide to withdraw and prescribe a different medication, or the reviewer can dismiss or deny the claim due to lack of communication from the prescriber; o If denied, the appeal process is available. o The appeal process: o If an initial review is denied, the Member may appeal the decision to have a different pharmacist reviewer evaluate the prior authorization. o If the denial is upheld upon first appeal, a second appeal may be made, which may be completed in consultation with a peer physician reviewer from an Independent Review Organization. o If the denial is again upheld upon second appeal, a final appeal for a Federal External Review completed by an Independent Review Organization may be made. o If the denial is upheld by the final review, the appeal process has been exhausted and the decision is final and binding. Foundational Utilization Management ("UM"). UM is a bundling of evidence -based clinical programs commonly used to provide appropriate clinical oversight of prescription drug claims. UM ensures the correct clinical evaluation processes are in place. Appropriate quantity limit ("t L") promotes FDA -approved dispensing guidelines and generally accepted medical treatment guidelines by ensuring appropriate quantities are dispensed. Step Therapy ("ST") ensures the most clinically appropriate item is used as initial therapy as part of adhering to generally accepted medical treatment guidelines. When faced with two similar agents, the lowest cost option is promoted first. Prior Authorizations ("PA") ensure FDA -approved and generally accepted medical treatment guidelines with respect to indications are being met. Utilizing the NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS