Contract Summary. OptumRx Administrative Services, LLC

Transcription

1 Contract Summary OptumRx Administrative Services, LLC Subcontractors This contract includes the following subcontractors or pass through to other providers. Name Service(s) Amount Interpreting Services International, Inc. Language Line Solutions MCMC LLC Translation services for written communication materials Translation of languages for customer service department Coordination of second level appeals and physician reviews Cost +20%, included in appeal charged to County. Convey Health Solutions Medicare Part D enrollment services administrative, if needed. The Rawlings Company Retrospective compliance audits Contractor retains 25% of recovered amounts. Medical Evaluation Specialists (MES) Medical Review Institute of America (MRIoA) Advanced Medical Reviews, Inc. (AMR) SureScripts Xerox Corporation SCIO Health Analytics Fiserv Output Solutions Independent Medical Review Services Prior Authorization (PA) and Appeals Claim Review Independent Medical Review Services Surescripts certifies the claims, eligibility, and medication history system/processes for e- prescribing purposes. Surescripts also serves as a network routing solution for transmitting eprescribing communications between OptumRx, EMR (electronic medical record), and pharmacy. Xerox prints and mails communications that include checks, explanations of benefits (EOB), and letters. Vendor provides audit application to OptumRx. The application is utilized by OptumRx staff to conduct audits of prescriptions provided to individuals. Digital print vendor prints membership cards well as other various letters. Cost +20%, which is external review charged to County. Cost +20%, which is included in the PA or appeal charged to County. Cost +20%, which is external review charged to County. $0.10 per eligibility and medication history transaction (eprescribe ). The proposed contract amendment modifies this. Page 1 of 6

2 Diamond Marketing Solutions Change Healthcare TeleTech Prints member and pharmacy check payments, explanations of payments (EOP). Direct Member Reimbursement payment processing. Provides overflow support services for customer service and pharmacy help desk. Attachment C Contract Operating Expenses current contract language I. COMPENSATION 1. County will pay Contractor for the services provided herein pursuant to the following table: TRADITIONAL MODEL Base Fees: Paper Claim Fee: Brand Drugs Generic MAC Drugs Non-MAC Generic Drugs Effective Overall Generic Guarantee (ingredient cost) Brand Drugs Generic MAC Drugs Non-MAC Generic Drugs Effective Overall Generic Guarantee (ingredient cost) Brand Drugs ONE 2015 TWO 2016 THREE 2017 FOUR 2018 Administrative Fees Retail 30: $0.00 per Claim Retail 90: $0.00 per Claim Mail Service: $0.00 per Claim Specialty: $0.00 per Claim $2.50 per paper claim (This is additive to the above indicated Base Fee. ) Retail 30 Pharmacy Network Lower of U&C or AWP minus 15.50% plus $1.35 dispensing Lower of U&C, OptumRx MAC plus $1.35 dispensing Lower of U&C or AWP minus 15.50% plus $1.35 dispensing Year 1: AWP minus 74.00% Year 2: AWP minus 74.50% FIVE (if 2019 Lower of U&C or AWP minus 17.00% plus $1.00 dispensing Lower of U&C, OptumRx MAC plus $1.00 dispensing Lower of U&C or AWP minus 17.00% plus $1.00 dispensing Year 3: AWP minus 77.00% Year 4: AWP minus 77.00% Year 5: AWP minus 77.00% Retail Pharmacy Network (> 83) Lower of U&C or AWP minus Lower of U&C or AWP minus 19.50% plus 18.50% plus $0.00 dispensing $0.00 dispensing Lower of U&C, OptumRx MAC plus $0.00 dispensing Lower of U&C or AWP minus 18.50% plus $0.00 dispensing Year 1: AWP Year 2: AWP minus 75.00% minus 75.50% Lower of U&C or AWP minus 19.50% plus $0.00 dispensing Year 3: AWP minus 78.00% Year 4: AWP minus 78.00% Year 5: AWP minus 78.00% OptumRx Mail Service Pharmacy** AWP minus 23.00% plus AWP minus 23.50% plus $0.00 dispensing $0.00 dispensing Page 2 of 6

3 TRADITIONAL MODEL Generic MAC Drugs Generic Non- MAC Drugs Effective Overall Generic Guarantee (ingredient cost) Retail 30 Minimum Retail 90 Minimum Mail Minimum Specialty Minimum ONE 2015 TWO 2016 AWP minus 23.00% plus $0.00 dispensing Year 1: AWP Year 2: AWP minus 76.00% minus 76.50% THREE 2017 FOUR (if 2018 OptumRx MAC plus $0.00 dispensing Attachment C FIVE (if 2019 AWP minus 23.50% plus $0.00 dispensing Year 3: AWP minus 80.00% Year 4: AWP minus 80.00% Specialty Pharmacy (Open) Dispensing Fees are $2.50 Dispensing Fees are $0.00 Rebates (Preferred 3-Tier, Catamaran Managed Formulary)*** $18.00 per $30.00 per $50.00 per $18.00 per specialty $65.00 per $65.00 per $ per $ per specialty **A minimum charge of $7.99 shall apply for all mail service orders. $ per $ per specialty Year 5: AWP minus 80.00% $ per $ per specialty ***Contractor will pass through to County 100% of Rebates and Manufacturer Administrative Fees it receives that can be attributed to allowable utilization of Participants hereunder. Contractor shall retain other earned revenue which is deemed separate and apart from Rebates and Manufacturer Administrative Fees. Premium Formulary rebates are contingent upon: Client's adoption, without deviation, of Contractor s formulary and formulary exclusions, as well as any changes Contractor makes to its formulary and formulary exclusions; and the implementation of the step therapies required by Contractor, as well as any changes Contractor makes to its formulary or utilization management programs; and a minimum 5 percent difference in coinsurance between preferred and non-preferred Brand Drugs. Page 3 of 6

4 Generic Dispensing Rate Guarantee Year 1 Year 2 Year 3 Year 4 (if Year 5 (if Retail 76.00% 77.00% 78.00% 78.00% 78.00% Mail 77.00% 78.00% 79.00% 79.00% 79.00% 2. ADDITIONAL SERVICES. Certain services as indicated below are not included in the standard Administrative Fee and are available for an additional charge. Program Fee (Years 1 5) Base Clinical Services (Shown Below) Included in Base Administrative Fee Concurrent DUR MTM/Retrospective DUR MTM = $0.62/PMPM; Total RDUR Fee = $0.33/per Rx (Includes Safe and Appropriate Utilization, Abused Medications and Gaps in Care). Inform Prescribing Program Quantity Limitations Prior Authorization Administrative Overrides Step Therapy Duration of Therapy Edits & Support Quarterly Clinical Program Reporting N/A No charge for standard reports Additional Clinical Programs Prior Authorization $40/per Clinical and Plan Tech Override $.10 per eligibility and medication eprescribing Product Services history transaction. Miscellaneous Fees Manual Eligibility Submission Formulary Delete Letter Ad Hoc Reports $150/Hour Physician Standard Appeals First Level Internal Clinical Appeal - $100/Appeal; Second Level Internal Clinical Appeal - $325/Appeal; First Level Internal Administrative Appeal - $75/Appeal; Second Level Internal Administrative Appeal - $244/Appeal; External Clinical Appeal - Cost + 20%; External Administrative Appeal - Cost + 20% Mailings of Welcome Packets Page 4 of 6

5 Program Fee (Years 1 5) Miscellaneous Fees Plan Prior Authorization Contractor Entered Plan Brochures (w/o prepaid envelope) Postage, Shipping and Handling Contractor retains 25% of recovered Claims Audit Review amount Develop and Distribute Communication Materials Twice per Calendar Year Develop and Distribute of Communication Material Beyond the Twice per Calendar Year at County's Request Mailing, Shipping and Handling Medicare Claims Files Submission and Support to $4,500 the County - RDS Support Services Optional (County may elect to add services at the costs stated below) Therapeutic Interchange $3.00/Intervention Communication Customization Cost varies depending on level of Customization. Customization, such as including the County's phone number and program name, are included. Personalization, such as addressing the letter Dear John Doe vs. Dear Member, will vary based on the level of customization. Dose Optimization $3.00/Intervention Adherence Management Member Outreach = $0.20 PMPM; Member & Prescriber Outreach = $0.36 PMPM II. PAYMENT 1. Payment Term-Payment in Arrears: a. Monthly and bi-monthly invoices are to be submitted in arrears. Claims shall be invoiced bimonthly on the 15 th and End of Month (EOM). Administrative s shall be invoiced monthly EOM. Contractor shall reference this Contract number on each invoice. Payment terms will be net 30 days of invoice date for administrative s and net 15 days of invoice date for claims. Invoices shall cover services not previously invoiced. The Contractor shall reimburse County for any monies paid to the Contractor for services not provided or when services do not meet the Contract requirements. Payments made by the County shall not preclude the right of the County from thereafter disputing any items or services involved or billed under this Contract and shall not be construed as acceptance of any part of the services. Page 5 of 6

6 2. Payment Invoicing Instructions: The Contractor will provide a two-part invoice on the Contractor s letterhead for services rendered. Each invoice will have a number and will include the following information: 1. Contractor s name and address 2. Contractor s remittance address, if different from 1 above 3. Name of County agency/department 4. Delivery/service address 5. Contractor/Subordinate Contract or Purchase Order number 6. Date of order 7. Type of s/service 8. Sales tax, if applicable 9. Dates of s/service 10. Brief description of s/service 11. Contractor s Federal I.D. Number The Contractor shall be fully responsible for providing an acceptable invoice to the County. Incomplete or incorrect invoices are not acceptable and will be returned to the Contractor for correction. Invoices and support documentation (Monthly Program Summary) is to be sent to: Project Manager, Barbara Voelkel Human Resource Services/Employee Benefits Hall of Administration 333 W. Santa Ana Blvd., Room 137 Santa Ana, CA Page 6 of 6