david y. ige board of trustees governor celeste …

DAVID Y. IGE BOARD OF TRUSTEES GOVERNOR CHRISTIAN FERN, CHAIRPERSON

CELESTE Y.K. NIP, VICE-CHAIRPERSON LAUREL JOHNSTON, SECRETARY-TREASURER RODERICK BECKER LINDA CURRIVAN MUSTO DAMIEN ELEFANTE STATE OF HAWAII AUDREY HIDANO OSA TUI CLIFFORD UWAINE

HAWAII EMPLOYER-UNION HEALTH BENEFITS TRUST FUND RYKER WADA 201 MERCHANT STREET, SUITE 1700

HONOLULU, HAWAII 96813 ADMINISTRATOR Oahu (808) 586-7390 DEREK M. MIZUNO

Toll Free 1(800) 295-0089 ASSISTANT ADMINISTRATOR www.eutf.hawaii.gov DONNA A. TONAKI

January 29, 2020

ADDENDUM NO. 2

TO

REQUEST FOR PROPOSALS

NO. 20-003

MEDICAL BENEFITS AND PHARMACY BENEFIT MANAGEMENT SERVICES

Following are responses to written questions received:

Question Answer

1 Please confirm the Intent to Bid form should have the EUTF Supplemental Copay plan noted as a self-insured (SI) option as opposed to fully-insured (FI)

Confirmed.

2 Questionnaire, Section D, Question #3: Was it the intent to inquire whether the respondent is currently providing DM/IHM services to a group of at least 100,000 covered members or 10,000 covered members?

At least 100,000 covered members.

3 Can we get an online log-in to the Segal or Proposal Tech site? We are having a hard time manipulating the PDF file, especially for the pricing tables. We want to work the RFP in your format.

All forms that need to be filled out and submitted with an Offeror’s proposal have been made available in Word format and posted to the State Procurement Office and the EUTF websites.

4 We sent in our NDA and ITB but haven’t received the data yet. We are concerned with the tight turn time and the amount of data that will be there. When can we get the claim data?

All Offerors who have submitted an NDA and ITB have been sent the claims and census data.

5 Will it be possible to get extra time for analysis of the custom formulary you currently have?

The proposal due date will be extended to February 5, 2020, 12:00 Noon, HST.

6 Page nos. 191, 192, and 199 Sections/Paragraphs: 2.1.1, 3.1.11, 3.1.12

Regarding Sections 2.1.1a, 2.1.1b, 3.1.11 and 3.1.12, EUTF is requesting that you use Medispan indicators to identify brand and generic drugs, except where the Brand Claim is submitted with a DAW code of 3,

EUTF’s Mission: We care for the health and well being of our beneficiaries by striving to provide quality benefit plans that are

affordable, reliable, and meet their changing needs. We provide informed service that is excellent, courteous, and compassionate.

City Financial Tower, 201 Merchant Street, Suite 1700, Honolulu, Hawaii 96813

www.eutf.hawaii.gov

RFP No. 20-003, Medical Benefits and Pharmacy Benefit Management Services Addendum No. 2 January 29, 2020

Please confirm the EUTF’s definition of generic and brand drugs. Sections 3.1.11 and 3.1.12 do not fully align with the definitions in 2.1.1a and 2.1.1b.

Our assumption is that we would use the definition in 2.1.1a and 2.1.1b for brand/generic drugs.

4, 5 or 6, in which case it shall be considered a Generic drug.

7 Page nos. 199, 200, 210, and 211 Sections/Paragraphs: 4.1.4, 4.1.12, 4.1.13 6.1.1 Contract Term 1, 6.1.2 Contract Term 2, 6.1.3 Contract Term 3, 6.1.4 Contract Term 4

Please clarify the EUTF's requested definition for Retail 30 vs Retail 90, as questions 4.1.4, 4.1.12 and 4.1.13 indicate Retail 30, 1-83 days supply and Retail 90, 84+ days supply. However, the pricing grids found in questions 6.1.1 Contract Term 1 to 6.1.4 Contract Term 4 state Retail 30, 1-30 days supply and Retail 90, 31–90 days.

Can you provide guidance if you are planning on changing the headers on the columns of the table, or can we add additional columns to match specifications in 4.1.4, 4.1.12 and 4.1.13.

The definition should be as follows: Retail 30, 1-30 days’ supply and Retail 90, 31+ days’ supply.

The column headings in the Pricing Tables are correct.

8 Pages 202, 246 Sections/Paragraphs: 4.1.25, 7.12.31

Please clarify the requested invoice turn around time. 4.1.25 requests 20 business days 7.12.31 requests 20 days Unless specified, when days are indicated, can we assume the EUTF means business days?

Please assume business days.

9 Page 223 Sections/Paragraphs: 6.8.1

Please clarify whether the requested 4% Trend Guarantee (question 6.8.1) is to be across the EUTF’s book of business or

The 4% Trend Guarantee is to be applied to the EUTF’s active employee and retiree plans separately.


separately for EGWP vs. commercial plans?

10 Pages: 224 Sections/Paragraphs: 6.8.3

Please clarify: The RFP asks to guarantee that the generic ingredient cost does not exceed 2% from year to year.

a. Is this across the book of business

or separately for EGWP vs.

Commercial?

b. What is the basis of this request?

Absolute $$, PMPY, etc.?

a. The 2% not-to-exceed guarantee is to be applied to EUTF’s active employee and retiree plans separately. b. The basis of the request is Per Member Per Year (PMPY).

11 Pages: 139 Sections/Paragraphs: Proposal Sheets

In reviewing the MAPD drug design, page 139 of RFP, and determined that some plan design elements do not appear to be compliant. Are bidders able to propose a CMS compliant plan only and not the plan supplied with the bid? Or, are you looking for a bid knowing some current plan design elements are not CMS compliant at this time?

Provide a proposal based on the plan design in the RFP with separate adjustments (i.e., additions or reductions in dollars) for non-compliant elements to the Total Monthly Medical Premium (Including DM/IHM and Administration and Retention) on page 141.

12 Pages: 139 Sections/Paragraphs: Proposal Sheets

Related to the question above: Does the EUTF want the EUTF and HSTA EGWP PDP drug designs to match the MAPD design as indicated in the bid?

Provide a proposal based on the plan design in the RFP with separate adjustments (i.e., additions or reductions in dollars) for non-compliant elements to the Total Monthly Medical Premium (Including DM/IHM and Administration and Retention) on page 142.

13 Pages: 143-144, 120, 139 Sections/Paragraphs: Proposal Sheets

What is the intent of Fully Insured Proposal Sheet 15B for the Medicare Advantage LPPO benefit plan for Medicare and Non-Medicare Retirees? Would this plan be offered along with the EUTF Retiree 90/10 PPO plan (proposal sheet 13)?

The benefit plan for the Non-Medicare Retirees is optional and allows the Contractor to enroll:

1. Non-Medicare retirees 2. Medicare retirees with Non-Medicare

spouses

If the Contractor did not have a Non-Medicare plan, enrollment in the Medicare Advantage plan would:

1. Be limited to Medicare retirees with only Medicare enrolled dependents.


2. Only occur during open enrollment or upon retirement of retirees eligible for Medicare (and whose dependents are all Medicare eligible).

The EUTF Board reserves the right to offer as many Non-Medicare Retiree and Medicare Retiree plans as deemed appropriate.

14 Pages: 219 (6.5.1), 224 (7.1.2), 302-305 (Exhibit K)

Please confirm if bidders should reference Exhibit K for both commercial and EGWP. We are assuming that we are to use entire drug list (drugs on page 302 -305) in Exhibit K as specialty drugs for commercial & EGWP. Is there a separate specialty drug list for commercial? Please explain if that is not accurate and how bidders should interpret the two sentences on the top of page 302.

Please see the attached Advanced Control Specialty Formulary for the commercial plans.

15 Pages: 143 Sections/Paragraphs: Proposal Sheet 15B

On Proposal Sheet 15B, are the requested Single, Two-Party, and Family rates for the Non-Medicare and Medicare populations based on the subscriber’s Medicare status?

Yes.

16 Pages 38-39 Sections/Paragraphs: Initial Reconciliation and Final Reconciliation

Do we settle annually for the initial 2-year contract?

Yes. The Initial Reconciliation will occur six (6) months following the end of the first and second plan years and the Final Reconciliation will occur 12 months following the end of the first and second plan years.

17 Sections/Paragraphs: Proposal Sheets sections

Should the offeror list the PCORI fee in the proposal sheets? There is a section currently labeled "Insurer Fee" which currently is $0 for all tiers, so is this a section where the PCORI fee could be populated?

Yes, list the PCORI fee in the section marked Insurer fee.

18 Pages 38-39 Yes, the medical and drug will be settled together. No deficits will be carried forward.


Sections/Paragraphs: Initial Reconciliation and Final Reconciliation

For the fully insured plans with risk sharing arrangement, if the same Carrier is awarded the medical and drug, will the medical and drug be settled together in the financial reconciliation by plan, where for example, surpluses from medical may be applied to offset deficits from drug?

19 Pages: Proposal Sheets #C Sections/Paragraphs: Proposal Sheets for Minimum Premium

Are the Limited Risk Sharing (minimum premium) proposals for Medical only? The header on the Minimum Premium proposal sheets reference medical and drug, but the proposal sheet does not have a section for drug.

If you are proposing a minimum premium arrangement for medical and prescription drug combined, include the total medical and prescription drug costs and note it accordingly on the proposal sheet.

20 Page 34 Section IV: Scope of Work 16. Health Data Reporting Requirement

Typically encounter data only applies to Medicaid. Please clarify this request.

The Health Data Reporting Requirement applies to both medical and prescription drug encounter data.

21 Page 34

Section IV: Scope of Work 16. Health Data Reporting Requirement

Please confirm whether this applies to self-insured PBM bids, or if it is related to medical/PPO only.

The Health Data Reporting Requirement applies to both medical and prescription drug encounter data.

22 Page 190

Section IX: Pharmacy Benefit Sheets 1.1 Core Requirements

Can you provide more information on how the current walk-in customer service center functions today? What is the volume of walk-in customers?

Walk-in traffic is very minimal. For example, for the six (6) months ending December 31, 2019, there was only one (1) walk-in member (includes commercial and EGWP plans).

23 Page 262

Section IX: Pharmacy Benefit Sheets

Question is amended to read: “Collect and validate Medicare MBI.”

https://esi.rfpio.com/#/respond/section/5e0fb310aa0b9c6924ac679b?q=5e0fb311aa0b9c6924ac67af

https://esi.rfpio.com/#/respond/section/5e0fb310aa0b9c6924ac679b?q=5e0fb311aa0b9c6924ac67af

https://esi.rfpio.com/#/respond/view/5e0f7ab252e7f757e2b72941?tab=clarifications&q=5e207ac6506f1f50017bdc50





7.19 Medicare Part D - Employer Group Waiver Plan (EGWP)

As of 12/31/2019, CMS will not accept HICN with the transition to MBI. Should vendor elect N/A, or is there an alternative version of the question that should be used?

24 Page 263

Section IX: Pharmacy Benefit Sheets 7.19 Medicare Part D - Employer Group Waiver Plan (EGWP)

Is this question asking if vendor can collect late enrollment penalties from Hawaii EUTF to complete the LEP process, or if vendor can collect late enrollment penalties from applicable members on Hawaii EUTF’s behalf?

We are asking if the vendor can collect late enrollment penalties from applicable members on the EUTF’s behalf and remit to CMS.

25 Page 286

Attachment 6, Performance Guarantees

Please clarify if "all online tools" encompasses all the tools that the EUTF and their members would have access to after their effective date, or if this is limited to open enrollment support tools.

“All online tools” includes access to the platform in order for the EUTF to have access to administrative, clinical, and financial parameters for them to assist their members (permitting certain access based on HIPAA) and reporting in aggregate for the whole group.

Members should also have access to the platform and any agreed upon services should be in effect by October 1, 2020.

This list of “all online tools” will be outlined and is subject to change based upon RFP and contract per the EUTF and Legal Counsel.

26 Page 289


Pharmacy Audit Resolution: Contractor guarantees credits resulting from Pharmacy Desk Top Audits will be applied to the EUTF’s invoice within 45 days of resolution.

“Resolution” is the credit amount that is determined to be owed to the EUTF based upon the Pharmacy Desk Top Audits results.

https://esi.rfpio.com/#/respond/section/5e0fa0ffaa0b9c6924ac598a?q=5e0fa100aa0b9c6924ac59dd




https://esi.rfpio.com/#/respond/section/5e136dc0aa0b9c6924ac6a84?q=5e136dc0aa0b9c6924ac6a89







Please clarify what you mean by “resolution”. We are interpreting it to mean “recovery”. Is that correct?

27 Page 291


Issue Resolution: Resolve 98.00% of enrollee issues within 3 business days.

What is the difference between this PG and the verbal issue resolution PG? Is this one for written inquiries?

Written Inquiry Answer Time includes only non-enrollment related written inquiries. Issue Resolution: Verbal Inquiries includes all verbal inquiries.

Issue Resolution includes enrollment related written inquiries and enrollment verbal inquiries not resolved at the first point of contact.

28 Please provide the average number of calls received by the current onsite customer service call center by line of business.

For the six (6) months ending December 31, 2019, the following were the total number of calls to the customer call center were:

• Commercial: 3,138

• EGWP: 10,059

29 How many customer service representatives are currently employed at the onsite customer service center?

This information will not be provided.

30 Please provide the average number of prior authorizations, appeals, and grievances per month (or annually), by line of business.

Appeals for the six (6) months ended November 30, 2019 for the commercial plans was 83.

31 Please provide the average number of DMRs (direct member reimbursement) per month (or annually).

Commercial plans average 73 per month. EGWP plans average 42 per month.

32 How many walk in visits does the customer service center experience in an average month?

Walk-in traffic is very minimal. For example, for the six (6) months ending December 31, 2019 there was only one (1) walk-in member (includes commercial and EGWP plans).

33 What clinical programs and utilization management programs are in place today?

Please see the attached programs.

34 Please clarify if the mail order facility is required to be wholly-owned and operated or can the facility be contracted?

The mail order facility may be contracted.

35 Question 7.17.11 – States “Can you provide a system edit to facilitate physician outreach in order to avoid partial fills? Explain.” Please confirm if this applies to only mail order or to all pharmacies.

This applies only to mail order.

36 Please provide a breakout of EGWP lives and Commercial lives.

Prescription drug members based on subscriber’s status:

https://esi.rfpio.com/#/respond/section/5e136dc5aa0b9c6924ac6ad8?q=5e136dc5aa0b9c6924ac6add

https://esi.rfpio.com/#/respond/section/5e136dc5aa0b9c6924ac6ad8?q=5e136dc5aa0b9c6924ac6add


Actives: 73,767 Non-Medicare Retirees: 10,188 Medicare Retirees: 45,349

37 Does EUTF intend to submit both commercial and EGWP enrollments on the same file?

No, the EUTF can submit the commercial and EGWP enrollments on separate 834 files. However, Medicare dependents of non-Medicare retirees will be included in the commercial file and non-Medicare dependents of Medicare retirees will be included in the EGWP file.

38 Question 7.2.6 – States “Confirm the PBM will not charge more than once for a Prior Authorization fee for a single prescription (e.g., the PBM won’t charge multiple times if they have to reach out to the doctor multiple times for a single prescription). Confirm the PBM will guarantee to charge the lowest of the Prior Authorization fee or the EUTF’s Net Cost (before rebates).”

Please provide clarification with regard to guaranteeing to charge the lowest of Prior Authorization fee or the EUTF’s Net Cost.

Please disregard, “Confirm the PBM will guarantee to charge the lowest of the Prior Authorization fee or the EUTF’s Net Cost (before rebates).” as it is not applicable.

39 With the answers and questions being pushed to a later date, do we anticipate an extension on the due date?

Please see response to question no. 5.

40 Network Data File: We don’t see a Provider Tax ID number on the disruption file and this is a required data element for our disruption reports. Could we please be provided the Provider Tax IDs?

Provider Tax ID numbers are not available. National Provider Identifiers (NPI) are provided for the disruption analysis.

41 Section I “Administrative Overview” Page 4, 1.4 Contract Period, Item 1 under Active Employee Plans and Item 1 under Retiree Plans (Non-Medicare and Medicare)

“Active Employee Plans: 1. First Contract Period -- July 1, 2021 -June 30, 2023 2. Optional Second Contract Period -- July 1, 2023 - June 30, 2024 3. Optional Third Contract Period -- July 1, 2024 - June 30, 2025

Retiree Plans (Non-Medicare and Medicare):

Requirement is premiums for two (2) separate 12-month periods.


1. First Contract Period -- January 1, 2021 - December 31, 2022 2. Optional Second Contract Period --January 1, 2023 - December 31, 2023

3. Optional Third Contract Period --January 1, 2024 - December 31, 2024”

Please confirm that for the first contract period for the Active and Retiree plans, EUTF is not requesting one set of premiums for a 24-month period, but instead two separate 12-month premiums.

42 Section I “Administrative Overview” Page 7, 1.11 Submission of Proposals, 2nd

paragraph

“Each qualified OFFEROR for Medical benefits may submit only one (1) proposal, although OFFERORS may propose to offer multiple plans within this RFP by completing and signing the appropriate forms. OFFERORS may submit proposals under all requested funding options, or only one (1) for any plan. Proposals for alternate benefit plans will not be accepted.”

Are we able to submit an additional plan for consideration?

Yes. Offerors may submit an additional plan for consideration; however, the EUTF is under no obligation to adopt the plan and it will not be evaluated for purposes of an award of contract under this RFP.

43 Section I “Administrative Overview” Page 8, 1.11 Submission of Proposals, 3rd

paragraph

“In addition to the proposals submitted to EUTF, OFFEROR shall submit, as a courtesy, two (2) signed hard copies of the proposal and ONE (1) ELECTRONIC copy on CD or USB flash drive to SEGAL to be received no later than Tuesday, February 4, 2020, 12:00 noon, HST to the attention of:

Mr. Stephen Murphy The Segal Company 330 North Brand Boulevard, Suite 1100

Glendale, CA 91203”

Double-sided is acceptable.


For the two hard copy, signed binders to Segal - can they be printed double-sided? Or should they be printed single sided, similar to the signed master copy for EUTF?

44 Section I “Administrative Overview” Page 13, 1.29 Special Conditions, Item 5 Inspections and Audits, Last sentence

“To the extent that Contractor proposes to use or uses any subcontractors to fulfill its obligations under the contract, those subcontractors must agree to abide by the record keeping, accounting, and audit requirements of the contract.”

We are willing to be ultimately responsible for providing all the services we've agreed to under this agreement. We have a number of provider contracts and other various contracts. We want to clarify that we do not need to get prior approval and we are not in violation of the contract if we contract with providers (or others) to provide services under this agreement. Can EUTF provide a definition of a "subcontractor"?

A subcontractor is a third party that the Contractor contracts with to perform services described in this RFP/contract. Network providers who provide health services to EUTF members will not be considered subcontracts for purposes of this RFP/contract.

45 Section X “Attachment 6: Performance Guarantee” Page 278, 2nd to the last row

“Guarantee: Achieve 99.00% of claims coded accurately. Random sampling is permitted with an error rate of 3.00% or less at a 95.00% confidence level.”

“Description: Number of claims (in the random sample) coded accurately / total number of claims for the quarter (in the random sample)”

We define claims coding accuracy as the number of claims paid without any financial errors which is in alignment with

Definition is acceptable.


the standard industry definition for Payment Incident/Claims Coding Accuracy below in Exhibit A.

46 Section X “Attachment 6: Performance Guarantees” Page 281, 1st row

“Guarantee: Load weekly 834 files within 24 hours after delivery by EUTF and process all transactions (e.g. enrollments, terminations, and other life events) including mailing of ID cards within 48 hours

Description: If the 834 file is electronically delivered Monday 7/29 10:00 a.m., all transactions must be loaded by Tuesday 7/30 10:00 a.m. and ID cards must be mailed by Thursday 8/1 10:00 a.m. If the 834 file is delivered Friday 8/2 10:00 a.m., all

transactions must be loaded by Monday 8/5 10:00 a.m.”

Is EUTF willing to discuss the ability to push the weekly 834 eligibility files as we have a few possible solutions?

The EUTF currently sends encrypted 834 files every Monday morning by 10:00 a.m., HST using secure file transfer protocol (SFTP) to a secure file server. The file server sends an email notification to the Contractor when a new file has been received, so that the Contractor can then connect to the file server to download the file. The EUTF is open to discussing an alternative file transfer method that meets HIPAA security requirements and does not add costs or additional time to the EUTF.

47 Section X “Attachment 6: Performance Guarantee” Page 287, first row

“Guarantee: Achieve 99.00% financial accuracy on claim payments. Random sampling is permitted with an error rate of 3.00% or less at a 95.00% confidence level.”

“Description: Number of claims paid (in the sample) with the correct eligible charge less the correct member coinsurance / total number of claims for the quarter (in the sample)”

Definition is acceptable.

48


Our understanding is that financial accuracy is relating to the dollars paid correctly or incorrectly, for that reason we use the standard industry definition for financial accuracy in Exhibit A below.

Exhibit A: Quality Quality Metric Definition / Metric Calculation

Financial (volume weighted) Financial accuracy accuracy is the percent of

payment ($) for external claims or allowed amount for encounters without any financial errors incurred throughout the process. Financial errors are under/over payments or financial error amounts. An error amount ($) is the absolute value of a under/over payment amount or error amount.

Payment (volume weighted) Payment incident incident accuracy is the accuracy percent of (Claims claims/encounters (#) coding without any financial errors accuracy) incurred throughout the

process. Financial errors are under/over payments or financial error amounts. A claim with multiple financial errors is counted once.

Section X “Attachment 6: Performance Guarantee” Page 288, 4th row

“Guarantee: Enrollment Accuracy - Achieve 99.00% accuracy on an annual reconciliation between the Contractor’s enrollees versus

The EUTF will compare enrollment reports from the EUTF and the vendor at a point in time. Timing differences (e.g., enrollment change made on EUTF but not transferred on the 834 file to the vendor) will be excluded. Other differences will be investigated to determine if it was due to EUTF or vendor error.


the EUTF’s enrollees, excluding enrollment differences due to timing.

Description: Errors (e.g. EUTF has a member enrolled on their file, but the same member is not enrolled by the Contractor and vice versa, not due to timing) / total enrolled by EUTF”

Please describe the process which will be used for the annual reconciliation between EUTF and the Contractor’s enrollees.

49 Page nos. 21, 50, 58, 66, 79, 105, 113, 129, 155

2.16: Requested Plan Design and Funding Arrangements Proposal Sheet 1C Proposal Sheet 2C Proposal Sheet 3C Proposal Sheet 5C Proposal Sheet 10C Proposal Sheet 11C Proposal Sheet 13C Proposal Sheet 16C

What is EUTF’s understanding of what the cash flow would be for Minimum Premium Arrangement (e.g, reserve, trust fund account, pay as you go, etc.)? How does the EUTF envision this working between EUTF and the carrier?

The EUTF’s preference is to utilize the carrier’s established banking arrangements to reimburse claims as incurred up to the monthly contractual limits. Additionally, the EUTF is open to advancing the carrier, prior to inception of the contract period, a historical estimate of the first month’s claims.

50 Page 287

Section X: Payment Accuracy and System Performance – Eligibility Data

Do state holidays extend the timeframe of the Performance Guarantee calculations? If we receive a file on the day before a holiday, is the holiday carved out of the calculation?

Yes, if the 834 file is electronically delivered Friday 5/22 10:00 a.m. and Monday 5/25 is a holiday (Memorial Day), all transactions must be loaded by Tuesday 5/26 10:00 a.m.

51 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”,

Just the EUTF. A Standard Formulary with Exclusions is not requested for HSTA VB plans.


Section I, page 3 states that Offerors may provide pricing for a Standard Formulary with Exclusions. Please confirm that the State would like this pricing proposal for both EUTF and HSTA VB plans.

52 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section I, page 3 states that Offerors may provide pricing for a Standard Formulary with Exclusions. Please clarify if EUTF would like a proposal for a Specialty Management formulary for HSTA VB members.

No. There is no need for a Specialty Management formulary for the HSTA VB plans.

53 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 193, question 2.1.1.g provides a definition of Rebates that includes “incentive rebates categorized as mail order purchase discounts”. Bidder does not contract for or receive any incentive rebates that it seeks to categorize as mail order purchase discounts, however, its affiliated mail order and specialty drug pharmacies do receive bona fide purchase discounts for things like prompt payment of invoices, total volume of drugs purchased to stock the pharmacy, etc. These amounts are not associated with any specific client’s formulary elections or claim volume, but are factored into Bidder’s cost of goods and reflected in the mail and specialty pharmacy discount guarantees we can offer. Please confirm that the successful PBM is not expected to pass through these bona fide purchase discounts.

Please specify what discounts the EUTF is entitled to on a pass-through basis, and what other bona fide purchase discounts are retained by the PBM.

54 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 199, question 4.1.4 requests confirmation of Retail 30 network guarantees for prescriptions with up to 83 days’ supply, and Retail 90 network guarantees with 84-90 days’ supply. However, the pricing tables found in questions 6.1.1 – 6.1.4 and 6.3.1 – 6.3.4 contradict the days’ supplies and state

The headings in the Pricing tables are correct: Retail 30 supply up to 30 days and Retail 90 supply 31-90 days.


“Retail Supply up to 30 days” and “Retail Supply 31-90 days”. Please clarify the requested days’ supply for network guarantees.

55 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 200, question 4.1.12 requests confirmation of Retail 90 pricing and rebates that adjudicate at the Retail 90 network with greater than 83 days’ supply. However, the pricing tables found in questions 6.1.1 – 6.1.4 and 6.3.1 – 6.3.4 contradict the days’ supplies and state “Retail Supply 31-90 days”. Please clarify the requested days’ supply for pricing and rebates adjudicating at the Retail 90 network.

Retail 30 supply up to 30 days and Retail 90 supply 31-90 days.

56 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 200, question 4.1.13 requests confirmation of Retail 30 pricing and rebates that adjudicate at the Retail 30 network for 1-83 days’ supply. However, the pricing tables found in questions 6.1.1 – 6.1.4 and 6.3.1 – 6.3.4 contradict the days’ supplies. Please clarify the requested days’ supply for pricing and rebates adjudicating at the Retail 30 network.

Retail 30 supply up to 30 days and Retail 90 supply 31-90 days.

57 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX – 4.1 Financial, page 203, Question 4.1.40 requires that unit cost for mail order must be equal to or lower than Retail, inclusive of U&C pricing. However, bidder does not have control over U&C costs at retail. Please confirm the unit cost equalization excludes U&C claims.

Confirmed, U&C claims are excluded.

58 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, pages 209 - 219, Tables in 6.1 – 6.4.4 requests Rebates on a per claim basis (brand and generic). This appears to be the only area that per claim Rebates are requested and several Requirements appear to allow per Brand claim Rebates,

Rebates are requested on a per Brand claim basis. Please indicate if you are proposing rebates on any other basis.


such as 3.1.1, 4.1.2, 4.1.15, and 4.1.18. Please clarify if Rebates are requested per claim or per Brand claim only.

59 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 226, question 7.2.6 states “Confirm the PBM will guarantee to charge the lowest of the Prior Authorization fee or the EUTF’s net cost (before rebates). Please further clarify the expectation of the State.

Please disregard, “Confirm the PBM will guarantee to charge the lowest of the Prior Authorization fee or the EUTF’s net cost (before rebates).” as it does not apply.

60 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 227, question 7.2.12 states “Does the PBM guarantee to refund the EUTF for every non-specialty drug over $1,000 that adjudicates that was not properly reviewed by the PBM”. Please clarify, or provide an example, to this statement in the question.

This question is eliminated.

61 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 227, question 7.3.1, please confirm that Act 226 allows EUTF plans to fill prescriptions at only a specific retail chain, limited or preferred network, and/or mail pharmacy.

This question is eliminated.

62 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 229, question 7.3.11 has a table with one column labeled “Retail 90 Network”. Please confirm that this table is also required for Retail 30 Network, EGWP Retail 30 Network and EGWP Retail 90 Network.

Confirmed.

63 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 232, question 7.6.2 contains a chart requesting the name of an IT Manager as part of the account team. Please clarify if the IT contact is to support IT for enrollment or for benefits.

The IT contact may have other roles and will be used as needed.

64 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 233, question 7.6.8, is

The EUTF is interested in what administrative procedures and best practices will be utilized to ensure that the PBM does not create unnecessary


EUTF agreeable to add “…plan design changes implemented by the EUTF…within 45 days of request/advisory, or on a mutually agreed upon date, as requested/advised by the EUTF.

duplicate ID cards that will be incorrectly charged to the EUTF when receiving and loading eligibility files.

65 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 234, question 7.6.19, please clarify if the file feeds include file transmission for audit purposes.

No, claims files for audits would be separate.

66 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX, page 244, question 7.12.4 is requesting Customer Service Call Center data from 2016. Please confirm that 2016 data is required.

Please provide Customer Service Call Center data for 2019 if possible. If not, provide for 2018.

67 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section X, page 287 - Eligibility Data, the performance guarantee contains 2 components 1) 24 hour load time of 834 files and 2) ID cards mailed within 4 business days. Since there are 2 components, is the $.15 penalty to be split for each component ($0.075 each) or is the penalty $0.15 for each ($0.30 total)?

If you miss one (1) component, the penalty is $0.15 PE/PR. If you miss both components, the penalty is $0.15 PE/PR.

68 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section X, page 288 – Client Approval of Enrollee Communications, this guarantee seems to have 2 components 1) 99.00% accuracy on communications to participants and 2) obtaining pre-approval of letters. Is the $0.10 penalty to be split for each component ($0.05 each) or is the penalty $0.10 for each component ($0.20)?

If you miss one (1) component, the penalty is $0.10 PE/PR. If you miss both components, the penalty is $0.10 PE/PR.

69 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section X, page 288 – Delivery of Reports, is EUTF willing to modify due dates on some reports to capture the most current data available? For example, a quarterly report due 35 days after the quarter ends, will have a quarter lag in rebates. A report for YE19, submitted 35 days later will

Yes, the EUTF is agreeable to negotiating due dates of reports.


include claims data through 4Q19 and rebate data through 3Q19.

70 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section X, page 289 – Delivery of Benefit Summaries, please confirm that this summary and SBC are excluded from the Delivery of Reports PF? If not, then they would be included under the Delivery of Reports PF and there should not be a separate PG line item with associated amount of risk.

Confirmed. Benefit summaries and SBCs are separate from the Delivery of Reports PG on page 288.

71 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section X, page 290 – Mailing Enrollee Materials, does this PG apply to welcome kids and ID cards for new members? If so, all of the Enrollee Materials and ID card is sent in a welcome kit. If for ID cards, there is a separate metric for ID cards.

The Mailing Enrollee Materials does not include the ID cards. ID card mailing is subject to the PG Eligibility Data on page 287.

72 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section X, page 291 – Issue Resolution, enrollee issues resolved within 3 business days. Does this refer to situations referred to the account team or through Care? If through the account team, many issues can be complex and take longer than 3 days to resolve. Are you agreeable to add “or as otherwise mutually agreed upon”. If it is not pertaining to questions submitted to the account team, is this PG referring to verbal inquires?

This PG does not apply to referrals to the account team.

73 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section X, page 291 – Enrollee Satisfaction Survey, are you agreeable to the following: “For the purposes of this guarantee, satisfaction shall be defined as Satisfied or better on the following 5-point sale: Completely Satisfied, Very Satisfied, Satisfied, Dissatisfied, Very Dissatisfied”.

Yes.

74 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section V, pages 43-162 Tables and Proposal Sheets, please confirm that a

Stand-alone PBM Offerors should complete the applicable prescription drug portions of the Tables and Proposal Sheets section. Pages 43-162 do not


stand-alone PBM bidder is not required to complete any portion of the Tables and Proposal Sheets in this section.

need to be completed if a proposal is not being submitted for these services.

75 With regard to Addendum 1, which extended the due date for responses to Vendor Questions, in order to incorporate any changes that might result from the responses to vendor questions, can the State provide an extension to the due date of the RFP response?


76 Offer Form OF-1 refers, in the first full paragraph, to “Specifications”. As this term is capitalized, can EUTF confirm whether it is intended to refer to one or more specific sections of the RFP?

This is a standard form and wherein the terms “Specification” and “Special Provisions” are used, the reference is to all of the terms, conditions, minimum qualifications and scope of work sections contained within this RFP.

77 If a bidder believes the parameters of its operational capabilities necessitate edits to the BAA attached as Exhibit F, should the bidder provide a redline of the BAA showing its requested edits, consistent with the instructions in RFP Section I.1.24 (Contract Execution) and the Section IV (Scope of Work) instructions?

Deviations from the State's Business Associate Agreement may be noted as an exception in the respective section as a red-line mark-up; however, there is no obligation for the EUTF to accept the changes.

78 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section I.1.24 (Contract Execution), page 11. If a PBM bidder believes certain relevant provisions that are not addressed in Section IX (Services to Be Provided), will EUTF discuss possible incorporation of such provisions at a later stage in the procurement? Should a bidder include any such provisions anywhere in its proposal?

Deviations from Section IX may be noted as an exception in the respective section as a red-line mark-up; however, there is no obligation for EUTF to accept the changes.

79 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section II, 2.2 (Subcontracting of Services), page 19, requires attaching statements from all proposed subcontractors regarding the scope of the subcontract and the subcontractor’s willingness to perform such tasks. Can EUTF confirm that this requirement applies to any new subcontractors proposed to support the EUTF business and not to third-party vendors already under contract with a

No, this requirement applies to both current and new subcontractors who the Contractor will contract with to perform services under this RFP/contract.


bidder to support ancillary services, like print production, across the bidder’s book of business?

80 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section IX (Services to Be Provided), subsection 2.1.1.m, page 194. Notwithstanding the requirement that eligibility and claims records must be the sole property of EUTF, is it EUTF’s expectation that (a) the successful PBM may retain claims data as necessary to complete services such as pharmacy auditing and in accordance with any applicable legal requirements after contract termination, and (b) the successful PBM may assert any rights it may have to protect certain elements of the claims records that constitute trade secret information from public disclosure?

Confirmed.

81 In the PDF document titled “RFP No. 20-003 Medical and PBM Services FINAL”, Section I, page 7. Can the Offeror provide the electronic redacted copy in PDF format with all proprietary and confidential, trade secret information redacted?

Yes.

82 Please provide the RFP to offerors in Microsoft Word format.

All forms that need to be filled out and submitted with an Offeror’s proposal have been made available in Word format and posted to the State Procurement Office and EUTF’s websites.

83 Please consider an extension for submission of proposals due to answers being posted on January 29, 2020, which may materially impact proposals that will need to go into production by January 30th

for the current due date of February 4, 2020.


84 Please confirm all questions in Section VII, Questionnaire should be answered by a carrier offering Medicare Advantage only.

Confirmed.

85 Please provide the Tax ID# (rather than NPI) for each provider in the Network Data file.

Provider Tax ID numbers are not available. National Provider Identifiers (NPI) are provided for the disruption analysis.

86 Please clarify which Performance Guarantee metrics apply if a carrier is only quoting Medicare Advantage with or

All Medical Plans metrics would apply for Medicare Advantage.


without Part D, for post-65 retirees. It appears the "All Medical Plans" metrics on pages 277-284 would apply, but we would like confirmation.

87 It appears the census provided does not include demographic information for dependents. Please provide an updated census, which includes dependents/spouses with date of birth, gender, plan option, and zip codes. Please indicate which, if any, of the members on the census under age 65 have Medicare Parts A & B as primary.

Spouse date of birth is provided in the census. All other requested information is not available.

88 For plans EUTF HMSA 90/10 PPO and EUTF Kaiser Comprehensive HMO, if any benefits changed from the claims experience period to the current benefit period, please provide the benefit summaries that would correspond with each benefit period.

Please refer to the EUTF website for Reference Guides and carrier benefit guides.

89 Please confirm if Part B drugs are included in the Medical claims provided or in the Rx claims provided.

HMSA medical claims includes, in general, non-specialty Part B drug claims. However, in general, the CVS Rx claims include the specialty drugs because specialty drugs are carved out of the EUTF HMSA plans. Kaiser claims were only provided for non-Medicare members and do not include Part B drug claims.

90 Please indicate whether retirees are allowed to come back on the plan if they have previously opted out of the employer sponsored plan.

Yes, as long as the retiree meets the eligibility requirements.

91 Moving forward, will the members who have Medicare as primary be eligible to remain on a Medicare Secondary plan in addition to the Medicare Advantage offering?


92 Is the intent for the Medicare Advantage plan to replace the existing Post 65 Medicare plans or be offered alongside?


93 Does the RFP require health plans to bid on pre-65 retirees in order to bid on the 65 and over population as well? Or can health plans bid on ONLY the 65 and over population?

Health plans may choose to propose ONLY on the Medicare Advantage LPPO plan and not include a Non-Medicare Plan proposal. However, health plans must propose on both the Non-Medicare and Medicare plans for the 90/10 PPO Plans, the Closed Panel HMO Plans and the stand-alone prescription drug.


94 The EUTF Supplemental Plan - Would the following scenario be considered a qualifying event for EUTF members to enroll in to the Supplemental Plan outside of open enrollment? An employee gets a non EUTF plan through a spouse’s medical plan mid year and is now eligible to enroll in the Supplemental plan if allowed to terminate from their EUTF PPO or HMO

Yes.

plan. If allowed, this would save both the employer and employee money.

January 2020

Advanced Control Specialty Formulary® The CVS Caremark®Advanced Control Specialty Formulary® is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

PLAN MEMBER Your benefit plan provides you with a prescription benefit program administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor.

Please note:

• Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market.

• Your prescription benefit plan design may alter coverage of certain products or vary copay1 amounts based on the condition being treated.

• You may be responsible for the full cost of non-formulary products that are removed from coverage.

• For specific information regarding your prescription benefit coverage and copay1 information, please visit Caremark.com or contact a CVS Caremark Customer Care representative.

• CVS Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription.

• In most instances, a brand-name drug for which a generic product becomes available will be designated as a nonpreferred option upon release of the generic product to the

HEAL TH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list.

Please note :

• Generics should be considered the first line of prescribing.

• The member's prescription benefit plan design may alter coverage of certain products or vary copay1 amounts based on the condition being treated.

• Th is drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member's specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to the market.

• The member's prescription benefit plan may have a different copay1 for specific products on the list.

• Unless specifically indicated, drug list products will include all dosage forms.

• Log in to Caremark.com to check coverage and copay1

information for a specific medicine.

market.

ANALGESICS

VISCOSUPPLEMENTS GEL-ONE GELSYN-3 SUPARTZFX VISC0-3

ANTI-INFECTIVES

ANTIRETROVIRAL AGENTS § ANTIRETROVIRAL COMBINATIONS abacavir-lamivudine lamivudine-zidovudine ATRIPLA BIKTARVY CIMDUO DESCOVY EVOTAZ GENVOYA ODEFSEY PREZCOBIX

SYMFI SYMFI LO TEMIXYS TRIUMEQ TRUVADA

FUSION INHIBITORS FUZEON

INTEGRASE INHIBITORS ISENTRESS TIVICAY

§ NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS efavirenz nevirapine nevirapine ext-rel EDURANT INTELENCE

§ NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir tablet didanosine lamivudine stavudine zidovudine EMTRIVA

§ NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS tenofovir disoproxil fumarate

§ PROTEASE INHIBITORS atazanavir lopinavir-ritonavir solution KALETRA TABLET NORVIR PREZISTA

ANTIVIRALS § HEPATITIS B AGENTS entecavir lamivudine tenofovir disoproxil fumarate BARACLUDE SOLU'flON VEMLIDY

§ HEPATITIS CAGENTS ribavirin EPCLUSA (genotypes 1, 2, 3, 4, 5, 6)

HARVONI (genotypes 1, 4, 5, 6)

VOSEVl 2

ANTINEOPLASTIC AGENTS

§ ALKYLATING AGENTS temozolomide

§ ANTIMETABOLITES capecitabine

HORMONAL ANTINEOPLASTIC AGENTS § ANTIANDROGENS abiraterone ERLEADA NUBEQA XTANDI YONSA

§ LUTEINIZING HORMONERELEASING HORMONE (LHRH) AGONISTS leuprolide acetate ELIGARD

IMMUNOMODULATORS REVLIMID THALOMID

§ KINASE INHIBITORS erlotinib imatinib mesylate AFINITOR

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their ap_pearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative. •CVS caremark~

https://Caremark.com



BOSULIF CENTRAL NERVOUS OVULATION STIMULANTS, AUTOIMMUNE AGENTS IMMUNOSUPPRESSANTS CABOMETYX SYSTEM GONADOTROPINS See Table 1 for Indication Based § ANTI METABOLITESIBRANCE Coverage Details GONAL-F § ANTICONVULSANTS mycophenolate mofetilIRESSA OVIDREL ANKYLOSING SPONDYLITIS mycophenolate sodiumKISQALI vigabatrin KISQALI FEMARA GAUCHER DISEASE COSENTYX § CALCINEURIN INHIBITORS§ MOVEMENT DISORDERSCO-PACK ENBRELCERDELGA cyclosporineRYDAPT tetrabenazine HUMIRACEREZYME cyclosporine, modifiedSPRYCEL AUSTEDO

CROHN'S DISEASE tacrolimusSUTENT INGREZZA HEREDITARY TYROSINEMIA TYKERB TYPE 1AGENTS HUMIRA § RAPAMYCIN DERIVATIVES§ MULTIPLE SCLEROSIS STELARAVOTRIENT ORFADIN sirolimusAGENTS SUBCUTANEOUS # § MISCELLANEOUS glatiramer HUMAN GROWTH

# After fa ilure of HU MIRA RESPIRATORY bexarotene capsule AUBAGIO HORMONES LYNPARZA BETASERON HUMATROPE PSORIASIS ALPHA-1 ANTITRYPSIN ODOMZO COPAXONE DEFICIENCY AGENTSHUMIRA

GILENYA § UREA CYCLE DISORDERSRUBRACA PROLASTIN-COTEZLA ZEJULA MAYZENT sodium phenylbutyrate SKYRIZI

REBIF § CYSTIC FIBROSISZOLINZA STELARAMISCELLANEOUSTECFIDERA tobramycinSUBCUTANEOUSCARDIOVASCULAR TYSABRI CYSTAGON inhalation solutionTALTZ

BETHKISANTILIPEMICS TREMFYAENDOCRINE AND HEMATOLOGIC PCSK9 INHIBITORS METABOLIC PULMONARY FIBROSISPSORIATIC ARTHRITISHEMATOPOIETIC GROWTH AGENTSREPATHA ACROMEGALY FACTORS COSENTYX

ESBRIETENBRELPULMONARY ARTERIAL SOMATULINE DEPOT ARANESP OFEVHUMIRAHYPERTENSION SOMAVERT NEULASTA OTEZLANIVESTYM SEVERE ASTHMA AGENTS§ ENDOTHELIN RECEPTOR CALCIUM RECEPTOR RETACRITANTAGONISTS DUPIXENTRHEUMATOID ARTHRITISANTAGONISTS UDENYCA FASENRAambrisentan ENBRELSENSIPAR NUCALAbosentan HEMOPHILIA AAGENTS HUMIRA

XOLAIROPSUMIT CALCIUM REGULATORS ORENCIA CLICKJECTADYNOVATE PARATHYROID HORMONES JIVI ORENCIA

§ PHOSPHODIESTERASE TOPICALSUBCUTANEOUSKOGENATE FSFORTEOINHIBITORS

KOVALTRY RINVOQ DERMATOLOGYTYMLOSsildenafil XELJANZNOVOEIGHT ATOPIC DERMATITIStadalafil MISCELLANEOUS XELJANZXRNUWIQ DUPIXENT PROSTACYCLIN RECEPTOR PROLIA

HEMOPHILIA BAGENTS ULCERATIVE COLITIS MOUTH/THROAT/AGONISTS CONTRACEPTIVES HUMIRAREBINYN DENTAL AGENTSUPTRAVI XELJANZ#PROGESTIN INTRAUTERINE PROTECTANTSHEREDITARY ANGIOEDEMADEVICESPROSTAGLANDIN #After failure of HUMIRA MUGARDFIRAZYRVASODILATORS KYLEENA

RUCONEST ALL OTHER CONDITIONS OPHTHALMICMIRENA SKYLA ENBREL RETINAL DISORDERS

ORENITRAM THROMBOCYTOPENIA

SOLUBLE GUANYLATE HUMIRAAGENTS EYLEAFERTILITY REGULATORSCYCLASE STIMULATOR$ LUCENTISMULPLETA DISEASE-MODIFYINGGNRHILHRHADEMPAS ANTIRHEUMATIC DRUGSANTAGONISTS IMMUNOLOGIC (DMARDs)CETROTIDE AGENTS RASUVO

ALLERGENIC EXTRACTS ORALAIR

A ATRIPLA bosentan COPAXONE E

abacavir tablet abacavir-lamivudine abiraterone ADEMPAS ADYNOVATE AFINITOR ambrisentan ARANESP atazanavir

AUBAGIO AUSTEDO

B BARACLUDE SOLUTION BETASERON BETHKIS bexarotene capsule BIKTARVY

BOSULIF

C

CABOMETYX capecitabine CERDELGA CEREZYME CETROTIDE CIMDUO

COSENTYX cyclosporine cyclosporine, modified CYSTAGON

D

DESCOVY didanosine DUPIXENT

EDURANT efavirenz ELIGARD EMTRIVA ENBREL entecavir EPCLUSA ERLEADA erlotinib

Your specific prescription benefit plan design may not cover certain products or categories , regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative. •cvsCaremark"


V

ESBRIET K NUCALA RUCONEST TREMFYA EVOTAZ NUWIQ RYDAPT TRIUMEQKALETRA TABLETEYLEA TRUVADAKISQALI 0 5 TYKERBKISQALI FEMARAF ODEFSEY SENSIPAR TYMLOSCO-PACK FASENRA ODOMZO si/denafil TYSABRIKOGENATE FS FIRAZYR OFEV sirolimusKOVALTRY uFORTEO OPSUMIT SKYLAKYLEENA FUZEON ORALAIR SKYRIZI UDENYCA

L ORENCIA CLICKJECT sodium pheny/butyrate UPTRAVI G ORENCIA SOMATULINE DEPOTJamivudine GEL-ONE SUBCUTANEOUS SOMAVERTlamivudine-zidovudine GELSYN-3 ORENITRAM SPRYCEL VEMLIDYJeupro/ide acetate GENVOYA ORFAOIN stavudine vigabatrinlopinavir-ritonavir solution GILENYA OTEZLA STELARA VISCO-3LUCENTIS glatiramer OVIDREL SUBCUTANEOUS VOSEVl 2

LYNPARZA GONAL-F SUPARTZ FX VOTRIENT p SUTENTM H XPREZCOBIX SYMFI

MAYZENT HARVONI PREZISTA SYMFI LO XELJANZMIRENA HUMATROPE PROLASTIN-C XELJANZXRMUGARD THUMIRA PROLIA XOLAIRMULPLETA

tacrolimus XTANDImycophenolate mofetilI R tadalafilmycophenolate sodium yTALTZ imatinib mesylate N REBIF TECFIDERA YONSA INGREZZA REBINYN

IBRANCE RASUVO

TEMIXYSNEULASTA

REPATHA temozolomide zINTELENCE nevirapine RETACRIT tenofovir disoproxil fumarateIRESSA ZEJULAnevirapine ext-rel tetrabenazineISENTRESS REVLIMID zidovudineNIVESTYM ribavirin THALOMID ZOLINZANORVIRJ RINVOQ TIVICAY

NOVOEIGHT RUBRACA tobramycinJIVI NUBEQA inhalation solution

~-: PREFERRED OPTIONS FOR EXCLUDED SPECIALTY MEDICATIONS 3 · ·.. ·

DRUG NAME(S PREFERRED OPTION S)* DRUG NAME(S PREFERRED OPTION S *

ADCIRCA sildenafil, tadalafil EXTAVIA glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, MAYZENT, REBIF, TECFIDERA, TYSABRI

ALPROLIX Consult doctor FOLLISTIM AQ GONAL-F

ASTAGRAFXL cyclosporine; cyc/osporine, modified; tacrolimus FULPHILA NEULASTA,UDENYCA

AVONEX glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, MAYZENT, REBIF, TECFIDERA, TYSABRI GENOTROPIN HUMATROPE

BARACLUDE TABLET entecavir, /amivudine, tenofovir disoproxif fumarate, GLEEVEC imatinib mesy/ate, BOSULIF, SPRYCEL BARACLUDE SOLUTION, VEMLIDY

GRANIX NIVESTYM BERINERT FIRAZYR. RUCONEST

HELIXATE FS ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, BUPHENYL sodium phenylbutyrate NOVOEIGHT, NUWIQ

CELLCEPT mycophenolate mofetil, mycophenolate sodium HEPSERA entecavir, lamivudine, tenofovir disoproxil fumarate, BARACLUDE SOLUTION, VEMLIDY

CHORIONIC OVIDREL GONADOTROPIN HYALGAN GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3

COMPLERA ATRIPLA, BIKTARVY, GENVOYA, ODEFSEY, SYMFI, LILETTA KYLEENA,MIRENA,SKYLA SYMFI LO, TRIUMEQ

LUPRON DEPOT ELIGARD DUROLANE GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 (For Prostate Cancer Only)

ELELYSO CERDELGA,CEREZYME MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 2

ELOCTATE ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ MONOVISC GEL-ONE, GELS¥N-3, SUPARTZ FX, VISCO-3

ENVARSUSXR cyclosporine; cyclosporine, modified; tacrolimus MYFORTIC mycophenofate mofetil, mycophenolate sodium

EPIVIR HBV entecavir, lamivudine, tenofovir disoproxil fumarate, NEUPOGEN NIVESTYM BARACLUDE SOLUTION, VEMLIDY

NORDITROPIN HUMATROPE

EPOGEN ARANESP, RETACRIT NOVAREL OVIDREL

EUFLEXXA GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative. •cvsCaremark"


DRUG NAMES PREFERRED OPTION S • DRUG NAMES PREFERRED OPTION S •

NUTROPINAQ HUMATROPE SAIZEN HUMATROPE

OMNITROPE HUMATROPE SANDOSTATIN LAR SOMATULINE DEPOT, SOMAVERT

ORTHOVISC GEL-ONE, GELSYN-3, SUPARTZ FX, VISC0-3 STRIBILD ATRIPLA, BIKTARVY, GENVOYA, ODEFSEY, SYMFI,

OTREXUP RASUVO SYMFI LO, TRIUMEQ

PEGASYS Consult doctor SYNVISC, SYNVISC-ONE GEL-ONE, GELSYN-3, SUPARTZ FX, VISC0-3

PLEGRIDY g/atiramer, AUBAGIO, BETASERON, COPAXONE, TASIGNA ima/inib mesy/a/e, BOSUUF, SPRYCEL

GILENYA, MAYZENT, REBIF, TECFIDERA, TYSABRI TOBI, TOBI PODHALER tobramycin inhalation solution, BETHKIS

PRALUENT REPATHA VERZENIO IBRANCE, KISQALI

PREGNYL OVIDREL VIEKIRAPAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6),

PROCRIT ARANESP, RETACRIT HARVONI (genotypes 1, 4, 5, 6)

PROCYSBI CYSTAGON XENAZINE tetrabenazine, AUSTEDO

PROGRAF tacrolimus ZARXIO NIVESTYM

RAPAMUNE sirolimus ZEMAIRA PROLASTIN-C

RAVICTI sodium phenylbutyrate ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6),

HARVONI (genotypes 1, 4, 5, 6) REVATIO sildenafil, tadalafil ZORTRESS sirolimus

SABRIL vigabatrin ZYTIGA abiraterone, XTANDI, YONSA

CONDITION EXCLUDED DRUG NAME(S) PREFERRED OPTION(S) . .

CIMZIA COSENTYX SIMPONI ENBREL TALTZ HUMIRA

CIMZIA HUMIRA ENTYVIO STELARA SUBCUTANEOUS #

HUMIRA COSENTYX CIMZIA

OTEZLA ENBREL SKYRIZI

STELARA SUBCUTANEOUS TALTZ TREMFYA

CIMZIA COSENTYX ORENCIA CLICKJECT ENBREL ORENCIA INTRAVENOUS HUMIRA ORENCIA SUBCUTANEOUS OTEZLA SIMPONI STELARA SUBCUTANEOUS TALTZ XELJANZ XELJANZXR

. a I . • • ENBREL CIMZIA ACTEMRA

HUMIRA KINERET ORENCIA CLICKJECT ORENCIA INTRAVENOUS ORENCIA SUBCUTANEOUS SIMPON! RINVOQ

XELJANZ XELJANZXR

HUMIRA SIMPONI ENTYVIOULCERATIVE COLITIS

XELJANZ #

ENBREL KINERET ACTEMRAALL! OTHER CONDITIONS

HUMIRA ORENCIA CLICKJECT ORENCIA INTRAVENOUS ORENCIA SUBCUTANEOUS

#After failure of HUMIRA

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their ap_pearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative. •CVS caremark·


You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The membe(s prescription benefit plan may have adifferent copay1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to Caremark.com to check coverage and copay1 information for aspecific medicine.

• The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. § Generics are available in this class and should be considered the first line of prescribing. 1 Copaymenl copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription

price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 For use in patients previously treated with an HCV regimen containing an NSSA inhibitor (for genotypes 1-6) or sofosbuvir without an NSSA inhibitor (for genotypes 1 a or 3). J An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.

©2019 CVS Caremark. All rights reserved. 106-31697C 010120 Caremark.com

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance ln this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative. •CVS caremark·




EUTF Clinical Programs •CVSHealth PRODUCT

Advanced Control Specialty Formulary

Compound Drugs and Miscellaneous Formulations (Core Compound strategy)

Diabetes Meter Program

Drug Savings Review

Generic Step Therapy

Generic Substitution at Mail (Mail DAW 1 & 2)

Lidocaine Strategy

Medical Devices Strategy

PRODUCT DESCRIPTION

Advanced Control Specialty Formulary (ACSF) is a moderately aggressive approach and presents specialty trend management. The formulary utilizes formulary exclusions, new-tomarket (NTM) drug management, tiering strategy and specialty guideline management (SGM) to help ensure clinically appropriate utilization and cost-effectiveness of specialty therapies. ACSF drug exclusions encompass the therapies offered for Specialty Preferred Drug Step Therapy (PDPD) and an additional twenty-one therapy classes.* Includes indication based strategies when appropriate (A drug can be strategically removed from formulary for an indication where it doesn 't work as well and other lower cost, similar, or more effective drugs are available) .

The Core Compound strategy is a comprehensive drug management strategy for commercial employer and health plans. This comprehensive strategy includes:

Compound Management: 1. Prior authorization for all compound drug claims more than $300 (no fill limit)

2. Exclusion of costly compounding bases, bulk compounding powders and compound kits to help our clients address and reduce compound utilization.

3. Exclusion of non-FDA approved topical analgesics (including Topical Analgesics, Scar and Otic Products, pain patches, ointments, creams, gels, etc., Multi-Product Kits, etc.)

Clients may choose the package, PA only, or Exclusion only.

Cost-savings program where the manufacturer provides a preferred blood glucose meter at no cost to those individuals currently using a non-preferred meter.

Identifies opportunities for improved prescribing and utilization based on evidence-based medical guidelines. Targets highly utilized classes with a high percentage of brand spend despite multiple generic options. Requires member to try one or two more generic options before a target brand is covered. Utilizing this option gives you the opportunity to increase your generic dispensing rate (GDR) and gross savings. You must opt-in to this product.

Generic Substitution @ Mail - is a mail order intervention program that educates members and physicians - before a prescription is filled - about generic equivalents to multi-source brand (MSB) medications. This is not the DAW penalties plan design benefit.

The Lidocaine strategy subjects FDA-approved products that are lidocaine or lidocainecontaining formulations to a quantity limit with a post-limit prior authorization requirement

The Medical Devices strategy uses PA criteria to manage cost and utilization for select Medical Devices and artificial saliva products with 51 Ok classification.

PRODUCT PRODUCT DESCRIPTION

Na"ive user - Days' Supply Limits for Preadolescents - 3 Day ..

Na"ive User - Days' Supply Limits - 7 Day

Opioid Utilization Management (UM) Clinical Edits

Restricts opioid-na"ive members, age 19 years or younger to a three-day or less supply of shortacting opioids.

Includes immediate release (IR) and immediate release combination opioid products. For clients adopting the enhanced opioid utilization management strategy, extended release products are not available to opioid-naive members.

For patients whose clinical diagnosis may require a longer day supply for ongoing therapy, prescribers can apply for prior authorization (PA).

Not intended for members with cancer, sickle cell disease or palliative care.

Available for commercial, Exchange and Medicaid clients. Not available for adoption by Medicare Part D and EGWP plans.

For 19 years and younger, use of an immediate release (IR ) before an extended release (ER) opioid for acute conditions is required for clients who do not have ER criteria.

Restricts opioid-naive members to a seven-day or less supply of short-acting opioids.

Includes immediate release (IR) and immediate release combination opioid products. For clients adopting the enhanced opioid utilization management strategy, extended release products are not available to opioid-naive members.

For patients whose clinical diagnosis may require a longer day supply for ongoing therapy, prescribers can apply for prior authorization (PA).

Not intended for members with cancer, sickle cell disease or palliative care.

Available for commercial, Exchange and Medicaid clients. Not available for adoption by Medicare Part D plans.

Enhanced opioid UM criteria that are aligned with the CDC Guideline recommendations to help improve management of opioid use and reduce potential misuse and abuse. This stricter criteria uses Morphine Milligram Equivalent (MME) to limit quantity of opioid products. Prior Authorization requests can be made if prescribers believe their patients should exceed the MME within the CDC recommendation. Not intended for patients with cancer, sickle cell disease or receiving pall iative or end-of-life care.

Pharmacy Advisor Support Adherence to Drug Therapy: Helps improve medication management and address potential adherence issues among members with targeted, chronic conditions

Pharmacy Advisor Support Automatic Refill: Promotes optimal adherence by helping members using CVS Caremark Mail Service Pharmacy refill and renew their prescriptions on time, avoiding lapses in therapy

Pharmacy Advisor Support Closing Gaps in Medication Therapy: Identifies gaps in medication therapy through daily review of pharmacy claims for members with six of the most common chronic conditions

Point of Sale Safety Messaging Point of Sale: Flags potential medication safety concerns at point of sale based upon the member's demographic and claims history.

Point-of-Sale (POS) Utilization Quantity Limits: Establishes a maximum quantity allowed over a period of time for medications Management with potential for overuse and misuse

Point-of-Sale (POS) Utilization Step Therapy: Automated step therapy edits that review a member's drug history to verify that a Management first-line therapy was attempted before the claim can be approved at the point of sale

Point-of-Sale (POS) Utilization Dose Optimization: Point-of-sale identification of opportunities where a higher-strength, single Management daily dose can be used in place of multiple daily doses, when available and clinically appropriate


A drug class management technique that requires select prescriptions meet defined criteria before they are covered by the plan. Requires prescribers to confirm medical necessity. Allows members to appeal a denied prior authorization request.

Prior Authorization (PA) and Appeals

Comprehensive solution through EHR (electronic health records) with actionable, up-to-the minute, member specific information available across multiple points of care. Provides greater visibility to member-specific OOP cost and benefit information to help members and their providers make more informed treatment decisions.

Real-Time Prescription Benefits

Retrospective: Reviews claims within 72 hours of adjudication to identify potential medication safety concerns

Retro Safety Review

SMS: Helps reduce instances of fraud, waste and abuse (FWA) through regular claims monitoring and timely interventions

Safety and Monitoring

· Retail pharmacy capability available to eligible patients that choose to fill their medications at their preferred CVS Pharmacy · Enables patients with multiple maintenance medications to pick up their eligible prescriptions together on the same date · Reduces prescription complexity by making it easier and more convenient for patients and caregivers to manage fulfillment of multiple maintenance medications at CVS Pharmacy · Digital support tools allow patients to manage aligned prescriptions 24/7; add or remove prescriptions and change the CVS Pharmacy pick-up date as needed

ScrlptSync

Eligibility criteria for patient prescription alignment: · Two or more eligible maintenance prescriptions · Includes enrollment of prescriptions in auto refill and auto renewal (to maintain synchronization)

Communicate the value of Specialty Connect, which combines the broad access and convenience of CVS Pharmacy with the clinical support and experience of our specialty pharmacists for all patients. Specialty Connect utilizes a predetermined specialty drug list to facilitate this electronic transfer functionality.

Specialty Connect

Specialty Expedite is an enhancement to the CVS Specialty onboarding process for enrolled prescribers that leverages use of Epic or another EHR system that participates in the Care quality Interoperability Framework. The streamlined onboarding process is designed to help patients get their medications sooner.

Specialty Expedite

NOTE: CVS Health uses and shares data as allowed by applicable law, and by our agreements and our information firewall. Some clients have specific requirements related to prior authorization submission (such as a physical prescriber signature). Specialty Expedite is only used where permissible by payor requirements and applicable law.

Program that promotes safe and appropriate utilization of specialty drugs by applying evidencebased guidelines before and throughout the course of therapy

Specialty Guideline Management

Specialty quantity limits is a tool that can help ensure safe and appropriate use of specialty medications, while also helping clients effectively manage therapies that can be subject to overuse.

Specialty Quantity Limits

(A core PBM service) Excludes coverage for all new-to-market unapproved products and certain Unapproved Drugs existing unapproved products that may be marketed contrary to the FD&C Act. Coverage will remain for select unapproved products that are legally marketed or deemed

(Management of Select Unapproved Products)

clinically necessary (e.g., because no alternatives exist). Note: This does not apply to EUTF non-Medicare Retirees

HSTA VB Clinical Programs •CVSHealth PRODUCT PRODUCT DESCRIPTION

Diabetes Meter Program

Cost-savings program where the manufacturer provides a preferred blood glucose meter at no cost to those individuals currently using a non-preferred meter.

Drug Savings Review Identifies opportunities for improved prescribing and utilization based on evidence-based medical guidelines.

Generic Step Therapy

Targets highly utilized classes with a high percentage of brand spend despite multiple generic options. Requires member to try one or two more generic options before a target brand is covered. Utilizing this option gives you the opportunity to increase your generic dispensing rate (GDR) and gross savings. You must opt-in to this product.

Generic Substitution at Mail (Mail DAW1 &2)

Generic Substitution @ Mail - is a mail order intervention program that educates members and physicians - before a prescription is filled - about generic equivalents to multi-source brand (MSB) medications. This is not the DAW penalties plan design benefit.

Pharmacy Advisor Support Adherence to Drug Therapy: Helps improve medication management and address potential adherence issues among members with targeted, chronic conditions

Pharmacy Advisor Support Automatic Refill: Promotes optimal adherence by helping members using CVS Caremark Mail Service Pharmacy refill and renew their prescriptions on time, avoiding lapses in therapy

Pharmacy Advisor Support Closing Gaps in Medication Therapy: Identifies gaps in medication therapy through daily review of pharmacy claims for members with six of the most common chronic conditions

Point of Sale Safety Messaging Point of Sale: Flags potential medication safety concerns at point of sale based upon the member's demographic and claims history.

Point-of-Sale (POS) Utilization Management

Quantity Limits: Establishes a maximum quantity allowed over a period of time for medications with potential for overuse and misuse

Point-of-Sale (POS) Utilization' Management

Dose Optimization: Point-of-sale identification of opportunities where a higher-strength, single daily dose can be used in place of multiple daily doses, when available and clinically appropriate

... Prior Authorization (PA) and Appeals

A drug class management technique that requires select prescriptions meet defined criteria before they are covered by the plan. Requires prescribers to confirm medical necessity. Allows members to appeal a denied prior authorization request.

Real-Time Prescription Benefits Comprehensive solution through EHR {electronic health records) with actionable, up-to-the minute, member specific information available across multiple points of care. Provides greater visibility to member-specific OOP cost and benefit information to help members and their

Retro Safety Review Retrospective: Reviews claims within 72 hours of adjudication to identify potential medication safety concerns

Safety and Monitoring SMS: Helps reduce instances of fraud , waste and abuse (FWA) through regular claims monitoring and timely interventions


ScriptSync · Retail pharmacy capability available to eligible patients that choose to fill their medications at their preferred CVS Pharmacy · Enables patients with multiple maintenance medications to pick up their eligible prescriptions together on the same date · Reduces prescription complexity by making it easier and more convenient for patients and caregivers to manage fulfillment of multiple maintenance medications at CVS Pharmacy · Digital support tools allow patients to manage aligned prescriptions 24/7; add or remove prescriptions and change the CVS Pharmacy pick-up date as needed

Eligibility criteria for patient prescription alignment: · Two or more eligible maintenance prescriptions · Includes enrollment of prescriptions in auto refill and auto renewal (to maintain synchronization)

Specialty Connect Communicate the value of Specialty Connect, which combines the broad access and convenience of CVS Pharmacy with the clinical support and experience of our specialty pharmacists for all patients. Specialty Connect utilizes a predetermined specialty drug list to facilitate this electronic transfer functionality.

Specialty Expedite Specialty Expedite is an enhancement to the CVS Specialty onboarding process for enrolled prescribers that leverages use of Epic or another EHR system that participates in the Care quality Interoperability Framework. The streamlined onboarding process is designed to help patients get their medications sooner.

NOTE: CVS Health uses and shares data as allowed by applicable law, and by our agreements and our information firewall . Some clients have specific requirements related to prior authorization submission (such as a physical prescriber signature). Specialty Expedite is only used where permissible by payor requirements and applicable law.

Specialty Guideline Management Program that promotes safe and appropriate utilization of specialty drugs by applying evidencebased guidelines before and throughout the course of therapy

Specialty Quantity Limits Specialty quantity limits is a tool that can help ensure safe and appropriate use of specialty medications, while also helping clients effectively manage therapies that can be subject to overuse.

e Script"

Appeals, SilverScript handles all Appeal, Redetermination, and Reconsideration Services in Redetermination and accordance with CMS requirements. Reconsideration Support Services

SilverScript uses Prior Authorization services to ensure that the proper clinical criteria are confirmed with the physician prior to allowing the medication to be filled under the Part D plan's benefit.

Prior Authorization

Formulary and P& T SilverScript develops and provides clinically appropriate, cost-effective, CMSCommittee compliant formularies. Management and Administration

SilverScript conducts Drug Utilization Review (DUR) edits which are performed online in real time between our mail and retail network pharmacies. Sample edits include duplicate drug therapy, drug-to-drug interaction, refill edits, and so forth .

Concurrent DUR

SilverScript offers a core solution that retrospectively evaluates pharmacy claims for patterns of potential fraud, overuse, or misuse. On a quarterly basis, SilverScript clinical pharmacists review controlled-substance and other select drug claims (along with supporting medical data, if available) to help identify potential medication abuse and fraudulent claims for appropriate intervention. In addition to the standard quarterly review, our clinical pharmacists review claims for the most conspicuous cases of overutilization and high cost on a monthly basis. The Safety and Monitoring Solution allows us to follow cases over time, facilitating our ability to ascertain if appropriate changes are made or additional follow up is needed.

Retrospective DUR

Retrospective Safety • Drug utilization review program with near real time review of claims 72 hour postclaim review.Review

• Interventions are directed to prescribers. • Utilizes a variety of edits to decrease drug trend, including:

Age appropriate edits

Condition management edits Appropriate therapy management

GI therapy management

Therapeutic duplication.

Page 1 Proprietary & Confidential © 2019 SilverScript Insurance Company. All Rights Reserved.

rScript" MTM SilverScript offers a CMS-approved Medication Therapy Management Program

(MTMP) for Medicare Part D members. All eligible Part D members that meet the targeting criteria are enrolled in the MTMP. If the member does not wish to participate in the MTMP, a toll-free number is provided in the Evidence of Coverage (EoC) materials with instructions to call this number to disenroll. The member can disenroll from the program at any time.

The MTM program is intended to decrease pharmacy trend . It also attempts to identify potentially inappropriate drug use in elderly beneficiaries and suggest a different type of drug therapy for seniors.

The SilverScript MTM program components include:

• One-on-one personalized telephonic counseling with a pharmacist

• Physician interventions to:

Help simplify drug therapy and reduce unnecessary therapy

- Evaluate for potentially inappropriate medications in elderly beneficiaries to address HRM scores

• Coordination with Medicare Health Support Organizations available (formerly known as CCIP).

Safety and Monitoring • Both Core and Enhanced programs provided Solution • Identify the misuse or overuse of controlled substance prescription drugs using

appropriate targeting criteria

• Detailed results reviewed by our pharmacists for need for plan action and follow up

• Detect and assist in preventing rising prescription drug abuse

• Multipoint checks for drug, doctor, and pharmacy fraud

• Important component of the CMS-mandated Fraud, Waste, & Abuse program .

• Enhanced program addresses severe instances of fraud, waste and abuse of controlled substances and includes access to clinical and criminal investigative staff.

Pharmacy Advisor • Identifies potential issues of non-adherence in select drug classes Support: Adherence to • Provides communication to prescriber and/or member to provide education about Drug Therapy the importance of medication adherence Pharmacy Advisor • Promoting evidence-based prescribing to help improve clinical outcomes Support: Closing Gaps • Review of pharmacy claims to identify potential opportunities to improve in Medication Therapy medication therapies for members with cardiovascular disease, diabetes,

osteoporosis, respiratory, and rheumatoid arthritis • Communication directed to prescriber

Proprietary & Confidential Page2 © 2019 SilverScript Insurance Company. All Rights Reserved.

•I Script"

Drug Saving Review • Review of all claims within 72 hours of adjudication.

• Review for potential safety and savings opportunities

• Interventions directed to prescribers.

Page 3 Proprietary & Confidential © 2019 SilverScript Insurance Company. All Rights Reserved.

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