Item F11 BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: November 19 2014 Division: — EmRloyee Services Division
Bulk Item- Yes X No — Department: Employee Benefits Department
Staff Contact Person/Phone#:- is Gonzalez X4448
AGENDA ITEM WORDING: Approval of EnvisionRx Options cost saving recommendations for
the 2015 plan year. Recommendation#1: Letter of Medical Necessity required on all compound
medications costing the plan $200 or more; Recommendation #2: Excluding some medications from
the member's out-of-pocket(OOP) thresholds for 2015.
ITEM BACKGROUND: EnvisionRx Options is recommending for our 2015 plan year to: 1) require
a letter of medical necessity on all compound medications costing the plan $200 or more; 2) The
Affordable Care Act (ACA) requires non-grandfath ere d group health plans to define Essential Health
Benefits (EHB) as it pertains totheir benefit. Beginning 2015 the member cost-sharing expenses of the
medications within the defined EHB when delivered by an in-network provider will accumulate toward
the member out-of-pocket (OOP) threshold of$6,350 (individual) and $12,700 (f ily). EnvisionRX
Options is recommending excluding the following drug categories from the member's OOP
accumulations: Acne Medications (cosmetic related only); Fertility; Impotency Drugs; Multivitamins;
Nutrients & Dietary Supplements (Rx only); OTC (over the counter) Products (items not covered under
ACA Preventive Services, if applicable); Smoking,Cessation and Weight Loss Drugs.
PREVIOUS RELEVANT BOCC ACTION: June 2011 BOCC approved to allow staff to negotiate
contract with EnvisionRX Options and a three year contract was approved by the BOCC at the
September 21, 2011 meeting. BOCC approved extending the contract through September 30, 2017 at
the September 17,2014 meeting.
CONTRACT/AGREEMENT CHANGES: N/A
STAFF RECOMMENDATIONS: Approval of recommendations effective 111115
TOTAL COST:r L1A &0jHvLnM :INDIRECT COST: BUDGETED Ye o s X N
teammendati,on LiLr.a R
DIFFERENTIAL OF LOCAL PREFERENCE:
COST TO COUNTY: $ SOURCE OF FUNDS:
REVENUE PRODUCING: Yes— No AMOUNT PER MONTH— Year
APPROVED BY: County Atty_ OMB/Purchasing_ Risk Management
DOCUMENTATION: Included Not Required............
DISPOSITION-. AGENDA ITEM#
* e
E N V I f 10 N
opirmi4f
RECOMMENDATION#1:
$200 Compound Letter of Medical Necessity
Envision recommends a Letter of Medical Necessity (LMN) on all compounds processing with a total plan
spend at or above $200. This recommendation is a cost-containment and utilization management strategy.
Please be aware that, if members attempt to utilize any compound medication costing the plan $200 or
more, this will result in a rejected claim requiring a LMN,
The responsibility of reviewing the LMN and providing a coverage determination will follow the Coverage
Determination and Appeals process.
RECOMMENDATION #2:
Essential Health Benefits' (Affordable Care Act)
The Affordable Care Act (ACA) requires non-grandfathered group health plans to define Essential
Health Benefits (EHB) as it pertains to their benefit. The member cost-sharing expenses of the
medications within the defined EHB when delivered by an in-network provider will accumulate towards
member out-of-pocket(OOP)thresholds.
Envision recommends all medications to be considered EHB with the exception of the
medications defined below. If this option is selected, these medications will not accumulate towards
the members OOP threshold defined by your plan,
Although excluding these medications from the member's OOP threshold is lEnvision's
recommendation, Plan Sponsors, if offering coverage for these medications, may elect to include these
medications in the members OOP calculations, Alternatively, you may also elect to exclude other
medications, in addition tothe medications listed below,from the members OOP accumulations.
Drugs recommended as non-EHB are listed below:
Drug Category Drug Class(11-.xample)
Acne Medications (Cosmetic Related Only)_ Tazorac@), Retin-AleD, Trentin-X6
xi il
Cosmetic Drugs ERenova(&, Minoxidil
Fertility PregnyM, Follistim(b, Gonal-Fs , BraveHeO, MenopurS
xl;. ..a I "z,_4_n
Impotency Drugs Viagra@, LevitraS, StendraV, Edex4D,CaverjectO,AnuseS
CialisO 2.5mg&5mg(Daily IED)",CiaftS 10mg&20mg
Multivitamins (items not covered under ACA-Preventive Prescription Vitamins(MephytonS)
Services, if applicable) Pediatric Vitamins
Nutrients&Dietary Supplements (Rx only) _ Deplins
OTC Products(items not covered under ACA-Preventive Claritin OTCO, Loratadine OTC, Pfliusec arce,_Zyrtec
Services,if applicable) OTC@, Cetirizine OTC
All Other OTCs
Smoking Cessation(items not covered under ACA ChantixS
Preventive Services, if applicable)
Weight Loss Drugs Phentermine,XenicaM