CTR051357_Contract_Amendment_5_-_PassThrough_Pricing_Sheet__Attach_4b_BAFO2__-_ADOA__6-3-2025_Update.xlsx.xlsx
XLSX spreadsheet 234 KB Posted
- Attached to
- Master Agreement AZ|CTR051357
- Contract number
- CTR051357
- Issued by
- Arizona
About this file
This document is a comprehensive Pass-Through Pricing Document for the State of Arizona's Employee Benefits Pharmacy Management contract (Solicitation No. BPM001729), featuring MedImpact Healthcare Systems, Inc. as the vendor. The document covers multiple pharmacy service models including Commercial, EGWP (Employer Group Waiver Plan), and various formulary configurations such as Custom, Standard, and Managed Formulary options with different carve-in and carve-out scenarios.
The contract encompasses pharmacy benefit management services with detailed pricing structures across multiple channels including retail, mail order, and specialty pharmacy. Pricing guarantees are provided for three contract years, with specific minimum effective discounts, maximum dispensing fees, and minimum rebate guarantees for generic and brand medications. The pricing model includes administrative fees ($0.85 per claim), various optional clinical programs, and credits such as a $100,000 implementation credit, administrative credits ranging from $1.50-$2.00 PMPY, and annual audit credits of $60,000. The contract also outlines comprehensive administrative services, including claims processing, drug utilization review, prior authorization, eligibility administration, and multiple optional clinical programs with associated fees and implementation costs.
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Custom Frmlry; All In, MID
| STATE OF ARIZONA | STATE OF ARIZONA | STATE OF ARIZONA |
| SOLICITATION NO.: BPM001729 | SOLICITATION NO.: BPM001729 | SOLICITATION NO.: BPM001729 |
| EMPLOYEE BENEFITS PHARMACY MANAGEMENT | EMPLOYEE BENEFITS PHARMACY MANAGEMENT | EMPLOYEE BENEFITS PHARMACY MANAGEMENT |
| ATTACHMENT 4-B PASS-THROUGH PRICING DOCUMENT | ATTACHMENT 4-B PASS-THROUGH PRICING DOCUMENT | ATTACHMENT 4-B PASS-THROUGH PRICING DOCUMENT |
| Vendor Name | MedImpact Healthcare Systems, Inc. | Vendor Name | MedImpact Healthcare Systems, Inc. | Vendor Name | MedImpact Healthcare Systems, Inc. |
| Formulary Name | MedPerform Medium | Vendor name | MedPerform Medium | Vendor name | MedPerform Medium |
| COMMERCIAL PASS-THROUGH PRICING MODEL - CUSTOM FORMULARY; ALL SERVICES CARVED IN | COMMERCIAL PASS-THROUGH PRICING MODEL - STANDARD FORMULARY; ALL SERVICES CARVED IN | COMMERCIAL PASS-THROUGH PRICING MODEL - STANDARD FORMULARY; ALL SERVICES CARVED IN |
Offerors shall complete all Questionnaires, Pricing Documents, and Cost Exhibits included in this solicitation, in the format indicated. Sections shall not be left blank or with a reference to find answer(s) elsewhere in the proposal. All cost items must be included and reflected only on the appropriate Pricing Document.
Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. All discount levels and fees shall be guaranteed minimums or maximums, as noted below. Responses that do not conform to this format will not be considered. Responses should be for a "Pass-through" pricing arrangement, which will be evaluated based on minimum guaranteed discounts, dispensing fees, and minimum rebates. Note (1) Show discount as a percent off of AWP for example (AWP - ____ %). Note (2) Rebates basis will be all filled brand prescriptions, whether rebatable or not (all rebates will be passed back to ADOA). Offerors shall complete all Questionnaires, Pricing Documents, and Cost Exhibits included in this solicitation, in the format indicated. Sections shall not be left blank or with a reference to find answer(s) elsewhere in the proposal. All cost items must be included and reflected only on the appropriate Pricing Document.
Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. All discount levels and fees shall be guaranteed minimums or maximums, as noted below. Responses that do not conform to this format will not be considered. Responses should be for a "Pass-through" pricing arrangement, which will be evaluated based on minimum guaranteed discounts, dispensing fees, and minimum rebates. Note (1) Show discount as a percent off of AWP for example (AWP - ____ %). Note (2) Rebates basis will be all filled brand prescriptions, whether rebatable or not (all rebates will be passed back to ADOA). Offerors shall complete all Questionnaires, Pricing Documents, and Cost Exhibits included in this solicitation, in the format indicated. Sections shall not be left blank or with a reference to find answer(s) elsewhere in the proposal. All cost items must be included and reflected only on the appropriate Pricing Document.
Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. All discount levels and fees shall be guaranteed minimums or maximums, as noted below. Responses that do not conform to this format will not be considered. Responses should be for a "Pass-through" pricing arrangement, which will be evaluated based on minimum guaranteed discounts, dispensing fees, and minimum rebates. Note (1) Show discount as a percent off of AWP for example (AWP - ____ %). Note (2) Rebates basis will be all filled brand prescriptions, whether rebatable or not (all rebates will be passed back to ADOA).
| COMMERCIAL CLAIMS | Guarantees (contract year 1) | COMMERCIAL CLAIMS | Guarantees (contract year 2) | COMMERCIAL CLAIMS | Guarantees (contract year 3) | |||||||||
| CHANNEL | (1) Minimum Effective Discount | Maximum Dispensing Fees per Rx | (2) Minimum Rebate Guarantee per Brand Rx | Comment | CHANNEL | (1) Minimum Effective Discount | Maximum Dispensing Fees per Rx | (2) Minimum Rebate Guarantee per Brand Rx | Comment | CHANNEL | (1) Minimum Effective Discount | Maximum Dispensing Fees per Rx | (2) Minimum Rebate Guarantee per Brand Rx | Comment |
| RETAIL | RETAIL | RETAIL | ||||||||||||
| GENERIC | AWP - 84.50% | $0.40 | GENERIC | AWP - 84.75% | $0.40 | GENERIC | AWP - 85.00% | $0.40 | ||||||
| BRAND | AWP - 18.75% | $0.40 | $214.00 (Per Brand Claim) | BRAND | AWP - 18.75% | $0.40 | $228.98 (Per Brand Claim) | BRAND | AWP - 18.75% | $0.40 | $245.01 (Per Brand Claim) | |||
| RETAIL - 90 | RETAIL - 90 | RETAIL - 90 | ||||||||||||
| GENERIC | AWP - 88.50% | $0 | GENERIC | AWP - 88.75% | $0 | GENERIC | AWP - 89.00% | $0 | ||||||
| BRAND | AWP - 22.75% | $0 | $642.00 (Per Brand Claim) | BRAND | AWP - 22.75% | $0 | $686.94 (Per Brand Claim) | BRAND | AWP - 22.75% | $0 | $735.03 (Per Brand Claim) | |||
| MAIL ORDER | MAIL ORDER | MAIL ORDER | ||||||||||||
| GENERIC | AWP - 89.00% | $0 | OPEN OR NON-MANDATORY | GENERIC | AWP - 89.25% | $0 | OPEN OR NON-MANDATORY | GENERIC | AWP - 89.50% | $0 | OPEN OR NON-MANDATORY | |||
| BRAND | AWP - 25.50% | $0 | $642.00 (Per Brand Claim) | BRAND | AWP - 25.50% | $0 | $686.94 (Per Brand Claim) | BRAND | AWP - 25.50% | $0 | $735.03 (Per Brand Claim) | |||
| SPECIALTY NON-LDD RETAIL | SPECIALTY NON-LDD RETAIL | SPECIALTY NON-LDD RETAIL | ||||||||||||
| GENERIC/BIOSIMILAR | Included in the Retail guarantee of AWP - 84.50% | Included in the Retail guarantee of $0.40 | $1,926.00 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | Included in the Retail guarantee of AWP - 84.75% | Included in the Retail guarantee of $0.40 | $2,060.82 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | Included in the Retail guarantee of AWP - 85.00% | Included in the Retail guarantee of $0.40 | $2,205.08 (Per Drug Claim) | EXCLUSIVE PROGRAM |
| BRAND | Included in the Retail guarantee of AWP - 18.75% | Included in the Retail guarantee of $0.40 | $1,926.00 (Per Brand Claim) | BRAND | Included in the Retail guarantee of AWP - 18.75% | Included in the Retail guarantee of $0.40 | $2,060.82 (Per Brand Claim) | BRAND | Included in the Retail guarantee of AWP - 18.75% | Included in the Retail guarantee of $0.40 | $2,205.08 (Per Brand Claim) | |||
| SPECIALTY LDD RETAIL | SPECIALTY LDD RETAIL | SPECIALTY LDD RETAIL | ||||||||||||
| GENERIC/BIOSIMILAR | Included in the Retail guarantee of AWP - 84.50% | Included in the Retail guarantee of $0.40 | $1,926.00 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | Included in the Retail guarantee of AWP - 84.75% | Included in the Retail guarantee of $0.40 | $2,060.82 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | AWP - 85.00% | Included in the Retail guarantee of $0.40 | $2,205.08 (Per Drug Claim) | EXCLUSIVE PROGRAM |
| BRAND | Included in the Retail guarantee of AWP - 18.75% | Included in the Retail guarantee of $0.40 | $1,926.00 (Per Brand Claim) | BRAND | Included in the Retail guarantee of AWP - 18.75% | Included in the Retail guarantee of $0.40 | $2,060.82 (Per Brand Claim) | BRAND | AWP - 18.75% | Included in the Retail guarantee of $0.40 | $2,205.08 (Per Brand Claim) | |||
| SPECIALTY NON-LDD MAIL | SPECIALTY NON-LDD MAIL | SPECIALTY NON-LDD MAIL | ||||||||||||
| GENERIC/BIOSIMILAR | AWP - 72.00% | $0 | $1,926.00 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | AWP - 72.00% | $0 | $2,060.82 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | AWP - 72.00% | $0 | $2,205.08 (Per Drug Claim) | EXCLUSIVE PROGRAM |
| BRAND | AWP - 18.25% | $0 | $1,926.00 (Per Brand Claim) | BRAND | AWP - 18.25% | $0 | $2,060.82 (Per Brand Claim) | BRAND | AWP - 18.25% | $0 | $2,205.08 (Per Brand Claim) | |||
| SPECIALTY LDD MAIL | SPECIALTY LDD MAIL | SPECIALTY LDD MAIL | ||||||||||||
| GENERIC/BIOSIMILAR | Included in the Specialty Non-LDD guarantee of AWP - 72.00% | $0 | $1,926.00 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | Included in the Specialty Non-LDD guarantee of AWP - 72.00% | $0 | $2,060.82 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | Included in the Specialty Non-LDD guarantee of AWP - 72.00% | $0 | $2,205.08 (Per Drug Claim) | EXCLUSIVE PROGRAM |
| BRAND | Included in the Specialty Non-LDD guarantee of AWP - 18.25% | $0 | $1,926.00 (Per Brand Claim) | BRAND | Included in the Specialty Non-LDD guarantee of AWP - 18.25% | $0 | $2,060.82 (Per Brand Claim) | BRAND | Included in the Specialty Non-LDD guarantee of AWP - 18.25% | $0 | $2,205.08 (Per Brand Claim) |
| Assumptions: | |||||
| The guarantees listed in this worksheet are based on the use of MedImpact's MedPerform Medium formulary, and MedImpact Direct as the exclusive Mail Order and Specialty provider. | |||||
| The specialty rebate guarantees listed in this worksheet apply to all specialty claims, regardless of where they are filled | |||||
| ADMINISTRATIVE FEE DETAIL SUMMARY | MedImpact Healthcare Systems, Inc. | ADMINISTRATIVE FEE DETAIL SUMMARY | MedImpact Healthcare Systems, Inc. | ADMINISTRATIVE FEE DETAIL SUMMARY | MedImpact Healthcare Systems, Inc. |
| Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. Responses that do not use this format will not be considered. All fees associated with this contract shall be listed. Any fee not stated herein is deemed to be included in the Base Administrative Fee. | Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. Responses that do not use this format will not be considered. All fees associated with this contract shall be listed. Any fee not stated herein is deemed to be included in the Base Administrative Fee. | Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. Responses that do not use this format will not be considered. All fees associated with this contract shall be listed. Any fee not stated herein is deemed to be included in the Base Administrative Fee. |
| Service | Proposed Fee | Fee Basis: PSPM, PMPM, Per Claim, Other | Fee Included In Base Admin Fee: | ||
| (Y) Yes or (N) No | Service | Proposed Fee | Fee Basis: PSPM, PMPM, Per Claim, Other | Fee Included In Base Admin Fee: | |
| (Y) Yes or (N) No | Service | Proposed Fee | Fee Basis: PSPM, PMPM, Per Claim, Other | Fee Included In Base Admin Fee: |
(Y) Yes or (N) No
| Base Administrative Services (see below): | Base Administrative Services (see below): | Base Administrative Services (see below): | |||||||||
| Commercial | $0.85 | Per Claim | Y | Commercial | $0.85 | Per Claim | Y | Commercial | $0.85 | Per Claim | Y |
| Base Administrative Services include but not limited to the following: | Base Administrative Services include but not limited to the following: | Base Administrative Services include but not limited to the following: |
| Account Management and Member Satisfaction Survey | Account Management and Member Satisfaction Survey | Account Management and Member Satisfaction Survey |
| All electronic claims processing (retail, mail, and specialty pharmacy) | All electronic claims processing (retail, mail, and specialty pharmacy) | All electronic claims processing (retail, mail, and specialty pharmacy) |
| Audit Support | Audit Support | Audit Support |
| Base Drug Utilization Review (DUR) | Base Drug Utilization Review (DUR) | Base Drug Utilization Review (DUR) |
| Base Prior authorization(PA) system edits & support | Base Prior authorization(PA) system edits & support | Base Prior authorization(PA) system edits & support |
| Base Quantity level limit(QLL)system edits & support | Base Quantity level limit(QLL)system edits & support | Base Quantity level limit(QLL)system edits & support |
| Clinical and Formulary Management | Clinical and Formulary Management | Clinical and Formulary Management |
| COB Administration | COB Administration | COB Administration |
| Data Management, File Transfers and Reporting | Data Management, File Transfers and Reporting | Data Management, File Transfers and Reporting |
| Decision support and plan design/formulary modeling | Decision support and plan design/formulary modeling | Decision support and plan design/formulary modeling |
| Duration of therapy edits & support | Duration of therapy edits & support | Duration of therapy edits & support |
| Electronic/POS Eligibility Administration (15 ADOA User Licenses) | Electronic/POS Eligibility Administration (15 ADOA User Licenses) | Electronic/POS Eligibility Administration (15 ADOA User Licenses) |
| Implementation /Transition Support | Implementation /Transition Support | Implementation /Transition Support |
| Mail Order and Specialty Pharmacy Operations | Mail Order and Specialty Pharmacy Operations | Mail Order and Specialty Pharmacy Operations |
| Manual Eligibility Administration | Manual Eligibility Administration | Manual Eligibility Administration |
| Member Communication Materials (open enrollment guide, plan descriptions, SBCs, pre-enrollment materials, welcome kit, ID card, formulary, and provider directory) | Member Communication Materials (open enrollment guide, plan descriptions, SBCs, pre-enrollment materials, welcome kit, ID card, formulary, and provider directory) | Member Communication Materials (open enrollment guide, plan descriptions, SBCs, pre-enrollment materials, welcome kit, ID card, formulary, and provider directory) |
| Member Services, Call Center and Member Website | Member Services, Call Center and Member Website | Member Services, Call Center and Member Website |
| Member Services, Call Center and Online Tools | Member Services, Call Center and Online Tools | Member Services, Call Center and Online Tools |
| Member Welcome Kit/Materials, Pre-Implementation Customized Mailing, ID Cards (Initial and Ongoing) | Member Welcome Kit/Materials, Pre-Implementation Customized Mailing, ID Cards (Initial and Ongoing) | Member Welcome Kit/Materials, Pre-Implementation Customized Mailing, ID Cards (Initial and Ongoing) |
| Network Management | Network Management | Network Management |
| Online Reporting Tool & Training for Users | Online Reporting Tool & Training for Users | Online Reporting Tool & Training for Users |
| Open Enrollment Support | Open Enrollment Support | Open Enrollment Support |
| Post Termination Standard Services | Post Termination Standard Services | Post Termination Standard Services |
| Pre-Implementation On Site Client Visit to Facility (including travel/stay) | Pre-Implementation On Site Client Visit to Facility (including travel/stay) | Pre-Implementation On Site Client Visit to Facility (including travel/stay) |
| Provider Call Support | Provider Call Support | Provider Call Support |
| Reporting Package (monthly, quarterly, annual, and ADHOC reports) | Reporting Package (monthly, quarterly, annual, and ADHOC reports) | Reporting Package (monthly, quarterly, annual, and ADHOC reports) |
| Step Therapy | Step Therapy | Step Therapy |
| Systems Maintenance | Systems Maintenance | Systems Maintenance |
| Therapeutic interchange (as required) | Therapeutic interchange (as required) | Therapeutic interchange (as required) |
| Web Access Capabilities and Personal Rx Histories | Web Access Capabilities and Personal Rx Histories | Web Access Capabilities and Personal Rx Histories |
| Paper Claims Processing | $1.50 | Per Claim | N | Paper Claims Processing | $1.50 | Per Claim | N | Paper Claims Processing | $1.50 | Per Claim | N | ||||||
| Clinical Prior Authorizations | $40.00 | Per Instance | N | Clinical Prior Authorizations | $40.00 | Per Instance | N | Clinical Prior Authorizations | $40.00 | Per Instance | N | ||||||
| Appeal Determinations(1st and 2nd Level) | $100 / $225 | Per Admin Appeal / Per 1st Level Clinical Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | Appeal Determinations(1st and 2nd Level) | $100 / $225 | Per Admin Appeal / Per 1st Level Clinical Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | Appeal Determinations(1st and 2nd Level) | $100 / $225 | Per Admin Appeal / Per 1st Level Clinical Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | |||
| Appeal Determinations External (3rd Level) | $350 | Per External Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | Appeal Determinations External (3rd Level) | $350 | Per External Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | Appeal Determinations External (3rd Level) | $350 | Per External Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | |||
| Additional Drug Utilization Review (DUR) | $0.00 PMPM | PMPM | Y | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": Standard DUE section for program description | Additional Drug Utilization Review (DUR) | $0.00 PMPM | PMPM | Y | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": Standard DUE section for program description | Additional Drug Utilization Review (DUR) | $0.00 PMPM | PMPM | Y | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": Standard DUE section for program description | |||
| Additional Quantity level limit(QLL)system | |||||||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Quantity level limit(QLL)system | |||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Quantity level limit(QLL)system | |||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | ||||||||||||||
| Additional Prior authorization(PA) system | |||||||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Prior authorization(PA) system | |||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Prior authorization(PA) system | |||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | ||||||||||||||
| Additional Step Therapy | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Step Therapy | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Step Therapy | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | ||||||
| Disease Management | $0.25 PMPM; | ||||||||||||||||
| $2,000 per month minimum fee | PMPM | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": RxGuide section for program description and listing of conditions included | Disease Management | $0.25 PMPM; | ||||||||||||
| $2,000 per month minimum fee | PMPM | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": RxGuide section for program description and listing of conditions included | Disease Management | $0.25 PMPM; | ||||||||||||
| $2,000 per month minimum fee | PMPM | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": RxGuide section for program description and listing of conditions included | ||||||||||||||
| Asthma | Asthma | Asthma | |||||||||||||||
| Diabetes | Diabetes | Diabetes | |||||||||||||||
| CHF | CHF | CHF | |||||||||||||||
| CAD | CAD | CAD | |||||||||||||||
| COPD | COPD | COPD | |||||||||||||||
| Other | Other | Other | |||||||||||||||
| Other | Other | Other | |||||||||||||||
| Wellness/Care Mgmt. Programs | Wellness/Care Mgmt. Programs | Wellness/Care Mgmt. Programs | |||||||||||||||
| Smoking Cessation | ASHLine consultations @ $22 each | ||||||||||||||||
| MMC consultations @ $30 each | Per Consultation | N | Smoking Cessation | ASHLine consultations @ $22 each | |||||||||||||
| MMC consultations @ $30 each | Per Consultation | N | Smoking Cessation | ASHLine consultations @ $22 each | |||||||||||||
| MMC consultations @ $30 each | Per Consultation | N | |||||||||||||||
| Other | Other | Other | |||||||||||||||
| Mail Order Expedited Shipping | $25.00 | Per Instance | N | Mail Order Expedited Shipping | $25.00 | Per Instance | N | Mail Order Expedited Shipping | $25.00 | Per Instance | N | ||||||
| MTM | $125.00 | Per Comprehensive Medication Review | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for program description | MTM | $125.00 | Per Comprehensive Medication Review | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for program description | MTM | $125.00 | Per Comprehensive Medication Review | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for program description | |||
| Commercial Postage (Client Requested) | Time and Materials | Per Instance | N | Commercial Postage (Client Requested) | Time and Materials | Per Instance | N | Commercial Postage (Client Requested) | Time and Materials | Per Instance | N | ||||||
| IT Programming/Forecasting | $225 | Per Hour | N | IT Programming/Forecasting | $225 | Per Hour | N | IT Programming/Forecasting | $225 | Per Hour | N | ||||||
| Additonal Optional Clinical Programs: | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for descriptions of all programs listed in rows 93-111. | Additonal Optional Clinical Programs: | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for descriptions of all programs listed in rows 93-111. | Additonal Optional Clinical Programs: | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for descriptions of all programs listed in rows 93-111. | ||||||||||||
| MedResults® Member/Prescriber Preferred Medication Communication Program | $7.00 per letter; |
$5,000 set-up fee per program;
$8,000 minimum fee per year per program;
$225/hour for scope changes Per Letter N MedResults® Member/Prescriber Preferred Medication Communication Program $7.00 per letter;
$5,000 set-up fee per program;
$8,000 minimum fee per year per program;
$225/hour for scope changes Per Letter N MedResults® Member/Prescriber Preferred Medication Communication Program $7.00 per letter;
$5,000 set-up fee per program;
$8,000 minimum fee per year per program;
| $225/hour for scope changes | Per Letter | N | |||||||||||
| RxOversight™ | $0.10 | PMPM | N | RxOversight™ | $0.10 | PMPM | N | RxOversight™ | $0.10 | PMPM | N | ||
| High Cost Generics Exclusion™ Program | $0.25 | PMPM | N | High Cost Generics Exclusion™ Program | $0.25 | PMPM | N | High Cost Generics Exclusion™ Program | $0.25 | PMPM | N | ||
| Enhanced Retrospective Drug Use Evaluation (DUE) Programs | $0.00 | PMPM | Y | Enhanced Retrospective Drug Use Evaluation (DUE) Programs | $0.00 | PMPM | Y | Enhanced Retrospective Drug Use Evaluation (DUE) Programs | $0.00 | PMPM | Y | ||
| Custom Retrospective Drug Use Evaluation (DUE) Programs | Quoted upon request and receipt of business requirements; | ||||||||||||
| Minimum $30,000/year | Per Instance | N | Custom Retrospective Drug Use Evaluation (DUE) Programs | Quoted upon request and receipt of business requirements; | |||||||||
| Minimum $30,000/year | Per Instance | N | Custom Retrospective Drug Use Evaluation (DUE) Programs | Quoted upon request and receipt of business requirements; | |||||||||
| Minimum $30,000/year | Per Instance | N | |||||||||||
| Refill Reminder Program | $0.30 PMPM; | ||||||||||||
| $5,000 set-up fee | PMPM | N | Refill Reminder Program | $0.30 PMPM; | |||||||||
| $5,000 set-up fee | PMPM | N | Refill Reminder Program | $0.30 PMPM; | |||||||||
| $5,000 set-up fee | PMPM | N | |||||||||||
| Choice90Rx Optimization Program | $0.30 PMPM; | ||||||||||||
| $5,000 set-up fee | PMPM | N | Choice90Rx Optimization Program | $0.30 PMPM; | |||||||||
| $5,000 set-up fee | PMPM | N | Choice90Rx Optimization Program | $0.30 PMPM; | |||||||||
| $5,000 set-up fee | PMPM | N | |||||||||||
| Quality Performance Monitoring Program (QPMP) Dashboard | $25,000 per year; | ||||||||||||
| $2,500 set-up fee | Per Year | N | Quality Performance Monitoring Program (QPMP) Dashboard | $25,000 per year; | |||||||||
| $2,500 set-up fee | Per Year | N | Quality Performance Monitoring Program (QPMP) Dashboard | $25,000 per year; | |||||||||
| $2,500 set-up fee | Per Year | N | |||||||||||
| Quality Performance Monitoring Program (QPMP) Data File Program: Monthly Reports | $12,000 per year per individual measure; |
$5,000 set-up fee Per Year N Quality Performance Monitoring Program (QPMP) Data File Program: Monthly Reports $12,000 per year per individual measure;
$5,000 set-up fee Per Year N Quality Performance Monitoring Program (QPMP) Data File Program: Monthly Reports $12,000 per year per individual measure;
$5,000 set-up fee
| Per Year | N | ||||||||||||
| Personal Health Report Card (PHRC) | $10.00 per report; | ||||||||||||
| $5,000 set-up fee | Per Report | N | Personal Health Report Card (PHRC) | $10.00 per report; | |||||||||
| $5,000 set-up fee | Per Report | N | Personal Health Report Card (PHRC) | $10.00 per report; | |||||||||
| $5,000 set-up fee | Per Report | N | |||||||||||
| Opioid Overutilization & Safety Controls Programs (9 program bundle) | $0.00 | PMPM | Y | Opioid Overutilization & Safety Controls Programs (9 program bundle) | $0.00 | PMPM | Y | Opioid Overutilization & Safety Controls Programs (9 program bundle) | $0.00 | PMPM | Y | ||
| MedPrescription Insight with Real-Time Benefit Check and ePA | $0.25 | Per Transaction | N | MedPrescription Insight with Real-Time Benefit Check and ePA | $0.25 | Per Transaction | N | MedPrescription Insight with Real-Time Benefit Check and ePA | $0.25 | Per Transaction | N | ||
| Custom Formulary Management | $75,000 | Per Year, Per Initial Formulary | N | Custom Formulary Management | $75,000 | Per Year, Per Initial Formulary | N | Custom Formulary Management | $75,000 | Per Year, Per Initial Formulary | N | ||
| Daily Cost Share Program | $0.02 PMPM; | ||||||||||||
| minimum program fee $500/month | PMPM | N | Daily Cost Share Program | $0.02 PMPM; | |||||||||
| minimum program fee $500/month | PMPM | N | Daily Cost Share Program | $0.02 PMPM; | |||||||||
| minimum program fee $500/month | PMPM | N | |||||||||||
| Enhanced Fraud, Waste & Abuse | $0.10 | PMPM | N | Enhanced Fraud, Waste & Abuse | $0.10 | PMPM | N | Enhanced Fraud, Waste & Abuse | $0.10 | PMPM | N | ||
| Client Requested Pharmacy Audits | $1400 - $2000 | Per Instance | N | Client Requested Pharmacy Audits | $1400 - $2000 | Per Instance | N | Client Requested Pharmacy Audits | $1400 - $2000 | Per Instance | N | ||
| MedIntegrate (Medical Specialty Management) | $0.25 | PMPM | N | MedIntegrate (Medical Specialty Management) | $0.25 | PMPM | N | MedIntegrate (Medical Specialty Management) | $0.25 | PMPM | N | ||
| MedAssist Copay Assistance Program | $0.25 | PMPM | N | MedAssist Copay Assistance Program | $0.25 | PMPM | N | MedAssist Copay Assistance Program | $0.25 | PMPM | N | ||
| Direct Messaging | In Development, Pricing TBD | TBD | N | Direct Messaging | In Development, Pricing TBD | TBD | N | Direct Messaging | In Development, Pricing TBD | TBD | N |
| CREDIT DETAIL SUMMARY | MedImpact Healthcare Systems, Inc. | |
| Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. Responses that do not use this format will not be considered. | ||
| Credit | Proposed Credit | Credit Basis: PEPM, PMPM, Per Claim, Other |
| Implementation Credit | $100,000 | One-Time |
| Pre-implementation Audit | $60,000 | One-Time |
| General Pharmacy Management Fund | $1.50 | PMPY Annually |
| Administrative Credit - Year One | $2.00 | PMPY |
| Administrative Credit - Year Two | $1.50 | PMPY |
| Administrative Credit - Year Three | $1.50 | PMPY |
| Annual Audit | $60,000 | Annual |
Custom Frmlry; All In, WAG
| STATE OF ARIZONA | STATE OF ARIZONA | STATE OF ARIZONA |
| SOLICITATION NO.: BPM001729 | SOLICITATION NO.: BPM001729 | SOLICITATION NO.: BPM001729 |
| EMPLOYEE BENEFITS PHARMACY MANAGEMENT | EMPLOYEE BENEFITS PHARMACY MANAGEMENT | EMPLOYEE BENEFITS PHARMACY MANAGEMENT |
| ATTACHMENT 4-B PASS-THROUGH PRICING DOCUMENT | ATTACHMENT 4-B PASS-THROUGH PRICING DOCUMENT | ATTACHMENT 4-B PASS-THROUGH PRICING DOCUMENT |
| Vendor Name | MedImpact Healthcare Systems, Inc. | Vendor Name | MedImpact Healthcare Systems, Inc. | Vendor Name | MedImpact Healthcare Systems, Inc. |
| Formulary Name | MedPerform Medium | Vendor name | MedPerform Medium | Vendor name | MedPerform Medium |
| COMMERCIAL PASS-THROUGH PRICING MODEL - CUSTOM FORMULARY; ALL SERVICES CARVED IN | COMMERCIAL PASS-THROUGH PRICING MODEL - STANDARD FORMULARY; ALL SERVICES CARVED IN | COMMERCIAL PASS-THROUGH PRICING MODEL - STANDARD FORMULARY; ALL SERVICES CARVED IN |
Offerors shall complete all Questionnaires, Pricing Documents, and Cost Exhibits included in this solicitation, in the format indicated. Sections shall not be left blank or with a reference to find answer(s) elsewhere in the proposal. All cost items must be included and reflected only on the appropriate Pricing Document.
Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. All discount levels and fees shall be guaranteed minimums or maximums, as noted below. Responses that do not conform to this format will not be considered. Responses should be for a "Pass-through" pricing arrangement, which will be evaluated based on minimum guaranteed discounts, dispensing fees, and minimum rebates. Note (1) Show discount as a percent off of AWP for example (AWP - ____ %). Note (2) Rebates basis will be all filled brand prescriptions, whether rebatable or not (all rebates will be passed back to ADOA). Offerors shall complete all Questionnaires, Pricing Documents, and Cost Exhibits included in this solicitation, in the format indicated. Sections shall not be left blank or with a reference to find answer(s) elsewhere in the proposal. All cost items must be included and reflected only on the appropriate Pricing Document.
Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. All discount levels and fees shall be guaranteed minimums or maximums, as noted below. Responses that do not conform to this format will not be considered. Responses should be for a "Pass-through" pricing arrangement, which will be evaluated based on minimum guaranteed discounts, dispensing fees, and minimum rebates. Note (1) Show discount as a percent off of AWP for example (AWP - ____ %). Note (2) Rebates basis will be all filled brand prescriptions, whether rebatable or not (all rebates will be passed back to ADOA). Offerors shall complete all Questionnaires, Pricing Documents, and Cost Exhibits included in this solicitation, in the format indicated. Sections shall not be left blank or with a reference to find answer(s) elsewhere in the proposal. All cost items must be included and reflected only on the appropriate Pricing Document.
Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. All discount levels and fees shall be guaranteed minimums or maximums, as noted below. Responses that do not conform to this format will not be considered. Responses should be for a "Pass-through" pricing arrangement, which will be evaluated based on minimum guaranteed discounts, dispensing fees, and minimum rebates. Note (1) Show discount as a percent off of AWP for example (AWP - ____ %). Note (2) Rebates basis will be all filled brand prescriptions, whether rebatable or not (all rebates will be passed back to ADOA).
| COMMERCIAL CLAIMS | Guarantees (contract year 1) | COMMERCIAL CLAIMS | Guarantees (contract year 2) | COMMERCIAL CLAIMS | Guarantees (contract year 3) | |||||||||
| CHANNEL | (1) Minimum Effective Discount | Maximum Dispensing Fees per Rx | (2) Minimum Rebate Guarantee per Brand Rx | Comment | CHANNEL | (1) Minimum Effective Discount | Maximum Dispensing Fees per Rx | (2) Minimum Rebate Guarantee per Brand Rx | Comment | CHANNEL | (1) Minimum Effective Discount | Maximum Dispensing Fees per Rx | (2) Minimum Rebate Guarantee per Brand Rx | Comment |
| RETAIL | RETAIL | RETAIL | ||||||||||||
| GENERIC | AWP - 84.50% | $0.40 | GENERIC | AWP - 84.75% | $0.40 | GENERIC | AWP - 85.00% | $0.40 | ||||||
| BRAND | AWP - 18.75% | $0.40 | $214.00 (Per Brand Claim) | BRAND | AWP - 18.75% | $0.40 | $228.98 (Per Brand Claim) | BRAND | AWP - 18.75% | $0.40 | $245.01 (Per Brand Claim) | |||
| RETAIL - 90 | RETAIL - 90 | RETAIL - 90 | ||||||||||||
| GENERIC | AWP - 88.50% | $0 | GENERIC | AWP - 88.75% | $0 | GENERIC | AWP - 89.00% | $0 | ||||||
| BRAND | AWP - 22.75% | $0 | $642.00 (Per Brand Claim) | BRAND | AWP - 22.75% | $0 | $686.94 (Per Brand Claim) | BRAND | AWP - 22.75% | $0 | $735.03 (Per Brand Claim) | |||
| MAIL ORDER | MAIL ORDER | MAIL ORDER | ||||||||||||
| GENERIC | AWP - 85.50% | $0 | OPEN OR NON-MANDATORY | GENERIC | AWP - 85.50% | $0 | OPEN OR NON-MANDATORY | GENERIC | AWP - 85.50% | $0 | OPEN OR NON-MANDATORY | |||
| BRAND | AWP - 25.50% | $0 | $642.00 (Per Brand Claim) | BRAND | AWP - 25.50% | $0 | $686.94 (Per Brand Claim) | BRAND | AWP - 25.50% | $0 | $735.03 (Per Brand Claim) | |||
| SPECIALTY NON-LDD RETAIL | SPECIALTY NON-LDD RETAIL | SPECIALTY NON-LDD RETAIL | ||||||||||||
| GENERIC/BIOSIMILAR | Included in the Retail guarantee of AWP - 84.50% | Included in the Retail guarantee of $0.40 | $1,926.00 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | Included in the Retail guarantee of AWP - 84.75% | Included in the Retail guarantee of $0.40 | $2,060.82 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | Included in the Retail guarantee of AWP - 85.00% | Included in the Retail guarantee of $0.40 | $2,205.08 (Per Drug Claim) | EXCLUSIVE PROGRAM |
| BRAND | Included in the Retail guarantee of AWP - 18.75% | Included in the Retail guarantee of $0.40 | $1,926.00 (Per Brand Claim) | BRAND | Included in the Retail guarantee of AWP - 18.75% | Included in the Retail guarantee of $0.40 | $2,060.82 (Per Brand Claim) | BRAND | Included in the Retail guarantee of AWP - 18.75% | Included in the Retail guarantee of $0.40 | $2,205.08 (Per Brand Claim) | |||
| SPECIALTY LDD RETAIL | SPECIALTY LDD RETAIL | SPECIALTY LDD RETAIL | ||||||||||||
| GENERIC/BIOSIMILAR | Included in the Retail guarantee of AWP - 84.50% | Included in the Retail guarantee of $0.40 | $1,926.00 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | Included in the Retail guarantee of AWP - 84.75% | Included in the Retail guarantee of $0.40 | $2,060.82 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | AWP - 85.00% | Included in the Retail guarantee of $0.40 | $2,205.08 (Per Drug Claim) | EXCLUSIVE PROGRAM |
| BRAND | Included in the Retail guarantee of AWP - 18.75% | Included in the Retail guarantee of $0.40 | $1,926.00 (Per Brand Claim) | BRAND | Included in the Retail guarantee of AWP - 18.75% | Included in the Retail guarantee of $0.40 | $2,060.82 (Per Brand Claim) | BRAND | AWP - 18.75% | Included in the Retail guarantee of $0.40 | $2,205.08 (Per Brand Claim) | |||
| SPECIALTY NON-LDD MAIL | SPECIALTY NON-LDD MAIL | SPECIALTY NON-LDD MAIL | ||||||||||||
| GENERIC/BIOSIMILAR | AWP - 64.00% | $0 | $1,926.00 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | AWP - 64.00% | $0 | $2,060.82 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | AWP - 64.00% | $0 | $2,205.08 (Per Drug Claim) | EXCLUSIVE PROGRAM |
| BRAND | AWP - 17.50% | $0 | $1,926.00 (Per Brand Claim) | BRAND | AWP - 17.50% | $0 | $2,060.82 (Per Brand Claim) | BRAND | AWP - 17.50% | $0 | $2,205.08 (Per Brand Claim) | |||
| SPECIALTY LDD MAIL | SPECIALTY LDD MAIL | SPECIALTY LDD MAIL | ||||||||||||
| GENERIC/BIOSIMILAR | Included in the Specialty Non-LDD guarantee of AWP - 64.00% | $0 | $1,926.00 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | Included in the Specialty Non-LDD guarantee of AWP - 64.00% | $0 | $2,060.82 (Per Drug Claim) | EXCLUSIVE PROGRAM | GENERIC/BIOSIMILAR | Included in the Specialty Non-LDD guarantee of AWP - 64.00% | $0 | $2,205.08 (Per Drug Claim) | EXCLUSIVE PROGRAM |
| BRAND | Included in the Specialty Non-LDD guarantee of AWP - 17.50% | $0 | $1,926.00 (Per Brand Claim) | BRAND | Included in the Specialty Non-LDD guarantee of AWP - 17.50% | $0 | $2,060.82 (Per Brand Claim) | BRAND | Included in the Specialty Non-LDD guarantee of AWP - 17.50% | $0 | $2,205.08 (Per Brand Claim) |
| Assumptions: | |||||
| The guarantees listed in this worksheet are based on the use of MedImpact's MedPerform Medium formulary, and Walgreens as the exclusive Mail Order and Specialty provider. | |||||
| The specialty rebate guarantees listed in this worksheet apply to all specialty claims, regardless of where they are filled | |||||
| ADMINISTRATIVE FEE DETAIL SUMMARY | MedImpact Healthcare Systems, Inc. | ADMINISTRATIVE FEE DETAIL SUMMARY | MedImpact Healthcare Systems, Inc. | ADMINISTRATIVE FEE DETAIL SUMMARY | MedImpact Healthcare Systems, Inc. |
| Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. Responses that do not use this format will not be considered. All fees associated with this contract shall be listed. Any fee not stated herein is deemed to be included in the Base Administrative Fee. | Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. Responses that do not use this format will not be considered. All fees associated with this contract shall be listed. Any fee not stated herein is deemed to be included in the Base Administrative Fee. | Complete the table below in the format provided. Use footnote references to clearly explain all qualifications or conditions. Responses that do not use this format will not be considered. All fees associated with this contract shall be listed. Any fee not stated herein is deemed to be included in the Base Administrative Fee. |
| Service | Proposed Fee | Fee Basis: PSPM, PMPM, Per Claim, Other | Fee Included In Base Admin Fee: | ||
| (Y) Yes or (N) No | Service | Proposed Fee | Fee Basis: PSPM, PMPM, Per Claim, Other | Fee Included In Base Admin Fee: | |
| (Y) Yes or (N) No | Service | Proposed Fee | Fee Basis: PSPM, PMPM, Per Claim, Other | Fee Included In Base Admin Fee: |
(Y) Yes or (N) No
| Base Administrative Services (see below): | Base Administrative Services (see below): | Base Administrative Services (see below): | |||||||||
| Commercial | $0.85 | Per Claim | Y | Commercial | $0.85 | Per Claim | Y | Commercial | $0.85 | Per Claim | Y |
| Base Administrative Services include but not limited to the following: | Base Administrative Services include but not limited to the following: | Base Administrative Services include but not limited to the following: |
| Account Management and Member Satisfaction Survey | Account Management and Member Satisfaction Survey | Account Management and Member Satisfaction Survey |
| All electronic claims processing (retail, mail, and specialty pharmacy) | All electronic claims processing (retail, mail, and specialty pharmacy) | All electronic claims processing (retail, mail, and specialty pharmacy) |
| Audit Support | Audit Support | Audit Support |
| Base Drug Utilization Review (DUR) | Base Drug Utilization Review (DUR) | Base Drug Utilization Review (DUR) |
| Base Prior authorization(PA) system edits & support | Base Prior authorization(PA) system edits & support | Base Prior authorization(PA) system edits & support |
| Base Quantity level limit(QLL)system edits & support | Base Quantity level limit(QLL)system edits & support | Base Quantity level limit(QLL)system edits & support |
| Clinical and Formulary Management | Clinical and Formulary Management | Clinical and Formulary Management |
| COB Administration | COB Administration | COB Administration |
| Data Management, File Transfers and Reporting | Data Management, File Transfers and Reporting | Data Management, File Transfers and Reporting |
| Decision support and plan design/formulary modeling | Decision support and plan design/formulary modeling | Decision support and plan design/formulary modeling |
| Duration of therapy edits & support | Duration of therapy edits & support | Duration of therapy edits & support |
| Electronic/POS Eligibility Administration (15 ADOA User Licenses) | Electronic/POS Eligibility Administration (15 ADOA User Licenses) | Electronic/POS Eligibility Administration (15 ADOA User Licenses) |
| Implementation /Transition Support | Implementation /Transition Support | Implementation /Transition Support |
| Mail Order and Specialty Pharmacy Operations | Mail Order and Specialty Pharmacy Operations | Mail Order and Specialty Pharmacy Operations |
| Manual Eligibility Administration | Manual Eligibility Administration | Manual Eligibility Administration |
| Member Communication Materials (open enrollment guide, plan descriptions, SBCs, pre-enrollment materials, welcome kit, ID card, formulary, and provider directory) | Member Communication Materials (open enrollment guide, plan descriptions, SBCs, pre-enrollment materials, welcome kit, ID card, formulary, and provider directory) | Member Communication Materials (open enrollment guide, plan descriptions, SBCs, pre-enrollment materials, welcome kit, ID card, formulary, and provider directory) |
| Member Services, Call Center and Member Website | Member Services, Call Center and Member Website | Member Services, Call Center and Member Website |
| Member Services, Call Center and Online Tools | Member Services, Call Center and Online Tools | Member Services, Call Center and Online Tools |
| Member Welcome Kit/Materials, Pre-Implementation Customized Mailing, ID Cards (Initial and Ongoing) | Member Welcome Kit/Materials, Pre-Implementation Customized Mailing, ID Cards (Initial and Ongoing) | Member Welcome Kit/Materials, Pre-Implementation Customized Mailing, ID Cards (Initial and Ongoing) |
| Network Management | Network Management | Network Management |
| Online Reporting Tool & Training for Users | Online Reporting Tool & Training for Users | Online Reporting Tool & Training for Users |
| Open Enrollment Support | Open Enrollment Support | Open Enrollment Support |
| Post Termination Standard Services | Post Termination Standard Services | Post Termination Standard Services |
| Pre-Implementation On Site Client Visit to Facility (including travel/stay) | Pre-Implementation On Site Client Visit to Facility (including travel/stay) | Pre-Implementation On Site Client Visit to Facility (including travel/stay) |
| Provider Call Support | Provider Call Support | Provider Call Support |
| Reporting Package (monthly, quarterly, annual, and ADHOC reports) | Reporting Package (monthly, quarterly, annual, and ADHOC reports) | Reporting Package (monthly, quarterly, annual, and ADHOC reports) |
| Step Therapy | Step Therapy | Step Therapy |
| Systems Maintenance | Systems Maintenance | Systems Maintenance |
| Therapeutic interchange (as required) | Therapeutic interchange (as required) | Therapeutic interchange (as required) |
| Web Access Capabilities and Personal Rx Histories | Web Access Capabilities and Personal Rx Histories | Web Access Capabilities and Personal Rx Histories |
| Paper Claims Processing | $1.50 | Per Claim | N | Paper Claims Processing | $1.50 | Per Claim | N | Paper Claims Processing | $1.50 | Per Claim | N | ||||||
| Clinical Prior Authorizations | $40.00 | Per Instance | N | Clinical Prior Authorizations | $40.00 | Per Instance | N | Clinical Prior Authorizations | $40.00 | Per Instance | N | ||||||
| Appeal Determinations(1st and 2nd Level) | $100 / $225 | Per Admin Appeal / Per 1st Level Clinical Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | Appeal Determinations(1st and 2nd Level) | $100 / $225 | Per Admin Appeal / Per 1st Level Clinical Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | Appeal Determinations(1st and 2nd Level) | $100 / $225 | Per Admin Appeal / Per 1st Level Clinical Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | |||
| Appeal Determinations External (3rd Level) | $350 | Per External Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | Appeal Determinations External (3rd Level) | $350 | Per External Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | Appeal Determinations External (3rd Level) | $350 | Per External Appeal | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for defintions of Administrative Appeals, First Level Clinical Appeals, and Second Level Clinical Appeals (External). | |||
| Additional Drug Utilization Review (DUR) | $0.00 PMPM | PMPM | Y | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": Standard DUE section for program description | Additional Drug Utilization Review (DUR) | $0.00 PMPM | PMPM | Y | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": Standard DUE section for program description | Additional Drug Utilization Review (DUR) | $0.00 PMPM | PMPM | Y | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": Standard DUE section for program description | |||
| Additional Quantity level limit(QLL)system | |||||||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Quantity level limit(QLL)system | |||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Quantity level limit(QLL)system | |||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | ||||||||||||||
| Additional Prior authorization(PA) system | |||||||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Prior authorization(PA) system | |||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Prior authorization(PA) system | |||||||||||||
| edits & support | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | ||||||||||||||
| Additional Step Therapy | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Step Therapy | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | Additional Step Therapy | $0.39 (Comprehensive Clinical Trend Management Fee) | PMPM | N | ||||||
| Disease Management | $0.25 PMPM; | ||||||||||||||||
| $2,000 per month minimum fee | PMPM | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": RxGuide section for program description and listing of conditions included | Disease Management | $0.25 PMPM; | ||||||||||||
| $2,000 per month minimum fee | PMPM | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": RxGuide section for program description and listing of conditions included | Disease Management | $0.25 PMPM; | ||||||||||||
| $2,000 per month minimum fee | PMPM | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial": RxGuide section for program description and listing of conditions included | ||||||||||||||
| Asthma | Asthma | Asthma | |||||||||||||||
| Diabetes | Diabetes | Diabetes | |||||||||||||||
| CHF | CHF | CHF | |||||||||||||||
| CAD | CAD | CAD | |||||||||||||||
| COPD | COPD | COPD | |||||||||||||||
| Other | Other | Other | |||||||||||||||
| Other | Other | Other | |||||||||||||||
| Wellness/Care Mgmt. Programs | Wellness/Care Mgmt. Programs | Wellness/Care Mgmt. Programs | |||||||||||||||
| Smoking Cessation | ASHLine consultations @ $22 each | ||||||||||||||||
| MMC consultations @ $30 each | Per Consultation | N | Smoking Cessation | ASHLine consultations @ $22 each | |||||||||||||
| MMC consultations @ $30 each | Per Consultation | N | Smoking Cessation | ASHLine consultations @ $22 each | |||||||||||||
| MMC consultations @ $30 each | Per Consultation | N | |||||||||||||||
| Other | Other | Other | |||||||||||||||
| Mail Order Expedited Shipping | $25.00 | Per Instance | N | Mail Order Expedited Shipping | $25.00 | Per Instance | N | Mail Order Expedited Shipping | $25.00 | Per Instance | N | ||||||
| MTM | $125.00 | Per Comprehensive Medication Review | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for program description | MTM | $125.00 | Per Comprehensive Medication Review | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for program description | MTM | $125.00 | Per Comprehensive Medication Review | N | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for program description | |||
| Commercial Postage (Client Requested) | Time and Materials | Per Instance | N | Commercial Postage (Client Requested) | Time and Materials | Per Instance | N | Commercial Postage (Client Requested) | Time and Materials | Per Instance | N | ||||||
| IT Programming/Forecasting | $225 | Per Hour | N | IT Programming/Forecasting | $225 | Per Hour | N | IT Programming/Forecasting | $225 | Per Hour | N | ||||||
| Additonal Optional Clinical Programs: | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for descriptions of all programs listed in rows 93-111. | Additonal Optional Clinical Programs: | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for descriptions of all programs listed in rows 93-111. | Additonal Optional Clinical Programs: | Please see "Attachment 3-A Supplement 3 - Clinical Programs. Commercial" for descriptions of all programs listed in rows 93-111. | ||||||||||||
| MedResults® Member/Prescriber Preferred Medication Communication Program | $7.00 per letter; |
$5,000 set-up fee per program;
$8,000 minimum fee per year per program;
$225/hour for scope changes Per Letter N MedResults® Member/Prescriber Preferred Medication Communication Program $7.00 per letter;
$5,000 set-up fee per program;
$8,000 minimum fee per year per program;
$225/hour for scope changes Per Letter N MedResults® Member/Prescriber Preferred Medication Communication Program $7.00 per letter;
$5,000 set-up fee per program;
$8,000 minimum fee per year per program;
| $225/hour for scope changes | Per Letter | N | |||||||||||
| RxOversight™ | $0.10 | PMPM | N | RxOversight™ | $0.10 | PMPM | N | RxOversight™ | $0.10 | PMPM | N | ||
| High Cost Generics Exclusion™ Program | $0.25 | PMPM | N | High Cost Generics Exclusion™ Program | $0.25 | PMPM | N | High Cost Generics Exclusion™ Program | $0.25 | PMPM | N | ||
| Enhanced Retrospective Drug Use Evaluation (DUE) Programs | $0.00 | PMPM | Y | Enhanced Retrospective Drug Use Evaluation (DUE) Programs | $0.00 | PMPM | Y | Enhanced Retrospective Drug Use Evaluation (DUE) Programs | $0.00 | PMPM | Y | ||
| Custom Retrospective Drug Use Evaluation (DUE) Programs | Quoted upon request and receipt of business requirements; | ||||||||||||
| Minimum $30,000/year | Per Instance | N | Custom Retrospective Drug Use Evaluation (DUE) Programs | Quoted upon request and receipt of business requirements; | |||||||||
| Minimum $30,000/year | Per Instance | N | Custom Retrospective Drug Use Evaluation (DUE) Programs | Quoted upon request and receipt of business requirements; | |||||||||
| Minimum $30,000/year | Per Instance | N | |||||||||||
| Refill Reminder Program | $0.30 PMPM; | ||||||||||||
| $5,000 set-up fee | PMPM | N | Refill Reminder Program | $0.30 PMPM; | |||||||||
| $5,000 set-up fee | PMPM | N | Refill Reminder Program | $0.30 PMPM; | |||||||||
| $5,000 set-up fee | PMPM | N | |||||||||||
| Choice90Rx Optimization Program | $0.30 PMPM; | ||||||||||||
| $5,000 set-up fee | PMPM | N | Choice90Rx Optimization Program | $0.30 PMPM; | |||||||||
| $5,000 set-up fee | PMPM | N | Choice90Rx Optimization Program | $0.30 PMPM; | |||||||||
| $5,000 set-up fee | PMPM | N | |||||||||||
| Quality Performance Monitoring Program (QPMP) Dashboard | $25,000 per year; | ||||||||||||
| $2,500 set-up fee | Per Year | N | Quality Performance Monitoring Program (QPMP) Dashboard | $25,000 per year; | |||||||||
| $2,500 set-up fee | Per Year | N | Quality Performance Monitoring Program (QPMP) Dashboard | $25,000 per year; |
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