1st Addendum 07/18/2012 DANNY L. KOLHAGE
CLERK OF THE CIRCUIT COURT
DATE: July 26, 2012
TO: Maria Z Fernandez - Gonzalez
Senior Administrator - Benefits
FROM: Pamela G. Hanco «�D. C.
At the July 18, 2012, Board of County Commissioner's meeting, the Board granted
approval and authorized execution of Item B30 Coverage Determination and Appeals Process
Addendum to the Pharmacy Benefit Management Services agreement with EnvisionRXOptions
to administer and invoice for both an internal and external appeals process for covered
individuals who wish to appeal the determination of non - coverage of a medication.
Enclosed is a duplicate original of the above - mentioned for your handling. Should you
have any questions please do not hesitate to contact this office.
cc: County Attorney w/o document
Finan e
File
COVERAGE DETERMINATION AND APPEALS PROCESS ADDENDUM
TO
PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT
This Coverage Determination and Appeals Process Addendum (hereinafter this "Addendum "),
effective as of the 1 day of January, 2012, is entered into by and between Envision
Pharmaceutical Services, Inc. (hereinafter "Envision "), and Monroe county Board of County
Commissioners (hereinafter "Plan Sponsor ").
RECITALS
WHEREAS, Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services
Agreement dated October 1 2011 (the "Agreement "), under which Envision provides PBM
Services to and on behalf of Plan Sponsor; and
WHEREAS, Plan Sponsor wishes for Envision to administer and invoice for both an internal and
external appeals process for Covered Individuals who wish to appeal the determination of non -
coverage of a medication under The Department of Health and Human Services 45 CFR Part 147
and the Department of Labor's 29 CFR Part 2590.
Now, therefore, Envision and Plan Sponsor agree as follows:
1. PBM Services
1.1 Envision shall administer a coverage determination and appeals process under
Plan Sponsor's direction as described in Exhibit 1 -A. The coverage
determination and appeals process will include: (i) real -time adjudication to
determine coverage /non - coverage status of a claim, (ii) initial determinations,
(iii) redeterminations, and (iv) external appeals utilizing an independent review
organization. The coverage determination and appeals process will meet the
requirements of the Department of Labor's 29 CFR 2590.715 -2719.
2. Plan Sponsor Responsibilities
2.1 Plan Sponsor shall pay Envision the following fees for the applicable steps
within the coverage determinations and appeal process.
Determinations Performed Internally by Envision
Initial coverage determination (Clinical Prior Authorization) $8.00
Redetermination $85.00
Independent Reviews Performed by Independent Review Organization (IRO)
Standard Turnaround Time (2 days or greater) 100% pass through invoice amount
from IRO.
Expedited Turnaround Time (Less than 2 days) 100% pass through invoice amount
from IRO.
Standard Turnaround Time for Complex Independent Review* 100% pass through invoice amount
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•
from IRO.
Expedited Turnaround Time for Complex Independent Review* 100% pass through invoice amount
•
from IRO.
*Complex Independent Review is defined as requiring greater than one hundred pages of clinical
documentation.
3. All other terms and conditions of the Agreement not modified by this Addendum or any
prior amendment or addenda shall remain unchanged.
•
IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Agreement as of the
Effective Date above.
For ENVISION: For PLAN SPONSOR:
B �� �� 66- �'• B
By: y.
/ Barry' . Katz, R. Ph., President
Mayor David P. Rice
Print Name and Title 07/18/2012
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EXHIBIT 1 -A
Envision Covera;_e Determination, Redetermination (Internal Appeal) and Independent
Review (External Appeal) Program Description (Revision date 09/16/2011)
EnvisionRxOptions maintains a process for coverage determinations, redeterminations and
independent review organization submissions. Envision utilizes a claim adjudication platform
to determine real -time coverage /non - coverage status for prescription claims submitted
electronically at the point of sale. Claims failing one or more benefit design coverage rules are
rejected at the point of sale and information regarding the reject reason(s) is conveyed to the
dispensing pharmacy at the point of sale. Pharmacy personnel may contact the Envision
Customer Service department to begin the coverage determination process or they may inform
the patient of the reason(s) for the rejection and provide the patient with instructions to contact
Envision Customer Service in the event the patient would like to initiate a coverage
determination.
Initial Determination
When a coverage determination request is initiated, the information from the rejected
prescription is conveyed by Envision to the patient's dispensing physician via fax with a request
for specific information regarding the patient's medication history and disease diagnosis. The
physician completes the form and returns it to Envision where the information provided by the
physician is evaluated by an Envision clinical pharmacist. Expedited request determinations
occur within 24 hours of receipt of the request and standard determinations occur within 72
hours of receipt of the request. If the information provided meets the criteria to allow an
override of the initial rejection, an override will be configured in the adjudication system that
will allow the claim to process. If the clinical review determines the prescription fails to meet
the coverage standard, the prescription will remain in rejected status. For approved coverage
determinations, a confirmation is communicated to the patient, the prescribing physician and the
dispensing pharmacy. In the event the coverage determination is denied, a Model Notice is used
for notification of the denial to the patient. The prescribing physician and the dispensing
pharmacy are also notified. The patient and prescribing physician are provided denial letters
with the specific reason for the denial and instructions about their right to initiate a
redetermination review (internal appeals process). Additionally, the model denial notice
provides information about the internal and external appeals process and also provides the
contact information for the HHS Office of Consumer Assistance.
Redetermination (First Level Internal Appeal )
A redetermination is the Envision equivalent to a first level internal appeal. Upon initiation of a
redetermination by the patient or their appointed representative, additional supporting
documentation may be received by Envision from the physician. Expedited redetermination
request evaluations occur within 24 hours of receipt of the request and standard evaluations
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occur within 72 hours of receipt of the request. The evaluation is performed by an Envision
clinical pharmacist other than the pharmacist that denied the original coverage determination
request to maintain impartiality within the review process. If the redetermination information
supports an override of the coverage determination denial, an override will be configured in the
adjudication system which will allow the claim to process. For approved redeterminations, a
confirmation is communicated to the patient, the prescribing physician and the dispensing
pharmacy. If evaluation determines the redetermination request fails to meet the coverage
standard, the prescription will stay in rejected status. Notification of the denial occurs via Model
Notice to the patient. The prescribing physician and the dispensing pharmacy are also notified.
The patient and prescribing physician are provided denial letters with the specific reason for the
denial. The model Final Internal Adverse Determination notice contains instructions about the
patient's right to initiate an independent review with an Independent Review Organization (IRO)
(information on the external appeals process) and also the contact information for the HHS
Office of Consumer Assistance.
External Appeal (Independent Review Organization)
When a patient or patient's appointed representative initiates an external appeal request with an
Independent Review Organization (IRO), Envision provides the claim information, plan
exclusion and coverage criteria documentation, and clinical review criteria to the IRO. This
external appeal request must be made within four months after the redetermination request (final
internal appeal decision). Envision is contracted with three separate IRO's to ensure an impartial
decision is reached for each request. External appeal requests are assigned and rotated to the
IRO's in succession to avoid selection bias. Each contracted IRO holds URAC accreditation
status to conduct external reviews. They are not bound by the previous redetermination decision
and review each case against the terms of the plan exclusion & coverage documentation. The
IRO will convey a final decision to Envision within 45 days for standard reviews and within 72
hours for expedited reviews. Expedited reviews are permitted when standard review timeframes
would seriously jeopardize the life or health of the patient.
If the IRO reverses Envision's adverse redetermination decision, then Envision will provide
coverage and/or payment of the claim within twenty -four hours of notification of the IRO
decision. If the IRO upholds Envision's adverse redetermination decision, the IRO will
communicate the decision to Envision and the member. If the physician files the request on
behalf of the patient, then the physician would be notified as well. The patient and prescribing
physician (if applicable) are provided denial letters with the specific reason for the denial and the
contact information for the HHS Office of Consumer Assistance.
Section 2719(a)(1)(B) requires that a group health plan and health insurance issuer offering
group or individual health coverage shall provide notice to enrollees, in a culturally and
linguistically appropriate manner, of available internal and external appeals processes. Under the
IFR at 45 CFR §147.136(e), plans and issuers meet the culturally and linguistically appropriate
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requirement if they provide notices, upon request, in the non - English language to populations
that meet the following thresholds:
• In the group market, for a plan that covers fewer than 100 participants at the beginning of
a plan year, the plan must make culturally and linguistically appropriate notices available
to populations in which 25 percent of all plan participants are literate only in the same
non - English language. For a plan that covers 100 or more participants at the beginning of
a plan year, the threshold is the lessor of 500 participants, or 10 percent of all plan
participants, being literate only in the same non - English language. The thresholds are
adapted from the Department of Labor's regulations regarding style and format for a
summary plan description, at 29 CFR 2520.102 -2(c).
• In the individual market, the determination of whether issuers are considered to be
providing relevant notices in a culturally and linguistically appropriate manner is made at
the county level. If at least 10 percent of the population residing in a county is literate
only in the same non - English language, the issuer must provide the appeals- related
notices in that language, upon request by an individual claimant residing in that county.
It is the Client's responsibility to notify Envision if one of these requirements is applicable to
their members.
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