The undersigned (“Client”) and [Caremark, L.L.C./CaremarkPCS Health, L.L.C. (“Caremark”)] are parties to a Prescription Benefit Services Agreement, as amended from time to time (“Agreement”), pursuant to which Client has retained Caremark to provide certain prescription benefit management and related services with respect to Client’s health benefit plan(s). Initially capitalized terms used herein and not expressly defined herein shall have the meanings given to such terms in the Agreement.
Included in the Services that may be provided by Caremark under the Agreement are certain core clinical services and programs and enhanced clinical programs and Services (“Clinical Services”). By executing and returning this Clinical Program Selection Form (“CPM”), Client confirms its election to have Caremark provide Clinical Services under the Agreement in accordance with this CPM.
This CPM is hereby incorporated by reference into the Agreement and shall form part of the Plan Design Document, as defined by the Agreement and the prescription drug benefit under Client’s applicable health benefit plan(s).
All Clinical Services shall be performed in accordance with the applicable criteria for such Clinical Service ("Criteria"). Unless Client elects below to use custom Criteria for one or more Clinical Services by so indicating on this CPM form, Caremark will provide each Clinical Service in accordance with its standard Criteria as in effect from time to time.Certain clinical services may only be used with standard criteria. The use of standard Criteria is part of the terms and conditions under which Caremark agrees to provide Clinical Services.Subject to the confidentiality provisions of the Agreement,such standard Criteria are proprietary and confidential information of Caremark. Such standard Criteria arenot part of Client's health plan or the Plan Design Document.Caremark reserves the right to modify any such standard criteria at any time and from time to time. Modifications of Criteria will not be routinely shared with Client.
To the extent that Client elects to use custom Criteria with respect to one or more Clinical Services, client shall provide Caremark with a copy of such Criteria in writing and Caremark will provide the related Clinical Services in accordance with such written Criteria. Caremark shall have no obligation to evaluateand/or update any custom Criteria for safety or efficacy and Client shall be responsible to notify Caremark of any changes to such criteria. For clients that wish to implement custom UM edit(s) that have already been developed for another line of business, please indicate this within the following sections of this form.
- Special Instructions/Notes section
- Client Request-Custom section at the end of each UM edit type area
Within these sections, please indicate the following: [ENTER SPECIFIC XYZ Plan List NAME] for each of the custom edits to be implemented.
Client may elect to discontinue provision of any Clinical Service through written notice to Caremark.
By signing below, Client hereby accepts and adopts as its own the Criteria, as administered by Caremark. In the event Client elects to implement its own criteria, Client acknowledges Caremark will not evaluate and update such custom criteria for safety or efficacy and Client shall be responsible to notify Caremark of any changes to such criteria.
I have reviewed the attached documentation and conclude all information to be correct.(All signatures below are required)
Client (Company) Name:Community Care Aliance of Illinois, NFP
Client Signature: / Date:10-04-2013
Signatory Name: Ellen Dooley
Signatory Title:Chief Operating Officer
2013 Core Clinical Programs
Manage Bad Trend
Utilization Management
Medication Safety / Medication Appropriateness
POS Safety Review / POS Utilization Management
Safety and Monitoring Solution / Dose Optimization
Retrospective Safety Review / Quantity Limits
Step Therapy
Specialty Guideline Management
Physician Profiling
Increase Use of Generics/Over-the-Counter Products (OTCs)
Generic Solutions
DAW 1 Solution / Targeted Generic Alternative Messaging (TGAM)
DAW 2 Solution / Value Drug Savings Tool
Generic Copay Incentive (GCI)
POS Preferred Product Messaging
Promote Good Trend
Improve Adherence and Close Gaps in Therapy
Pharmacy Advisor Support: Pharmacy Advisor Support includes programs to promote adherence, close gaps in medication therapy, provide first fill counseling at CVS pharmacies, and access to the Pharmacy Advisor specialty care team.
Pharmacy Advisor Support: Adherence
Pharmacy Advisor Support: ReadyFill at Mail
Pharmacy Advisor Support: Closing Gaps in Medication Therapy
CVS Retail Offering
ExtraCare® Health Card (ECHC)
NOTE: PLEASE COMPLETE THE CLINICAL IMPLEMENTATION FORM AS NEEDED TO SET UP SPECIFIC PROGRAMS
2013 Enhanced Clinical Programs
Manage Bad Trend
Enhanced Utilization Management
Medication Safety / Medication Appropriateness
Enhanced Safety and Monitoring Solution / Drug Savings Review
Prior Authorization/Appeals
Medication Therapy Counseling
Genetic Benefit Management
Increase Use of Generics/Over-the-Counter Products (OTCs)
PerformanceRx®*
Promote Good Trend
Improve Adherence and Close Gaps in Therapy
Pharmacy Advisor Counseling at CVS:
Pharmacy Advisor Counseling at CVS includes Pharmacy Advisor Support plus member-specific face to face interventions at CVS pharmacies, and inbound phone support provided by pharmacists for members who use Caremark mail or other network pharmacies.
Pharmacy Advisor Counseling All Channels:
Pharmacy Advisor Counseling All Channels includes Pharmacy Advisor Support plusmember-specific face to face interventions at CVS pharmacies, and both outbound and inbound phone support provided by pharmacists for members who use Caremark mail or other network pharmacies.
Pharmacy Advisor Condition Alerts:
Pharmacy Advisor Condition Alerts uses both pharmacy and medical claims data to identify and address gaps in care across a broad range of conditions. Following the identification of a gap in care, CVS Caremark will communicate, as appropriate, with the member and the member’s physician to close the gap in care.
Disease Management
NOTE: PLEASE COMPLETE THE CLINICAL IMPLEMENTATION FORM AS NEEDED TO SET UP SPECIFIC PROGRAMS
*Some programs may be funded by pharmaceutical manufacturers.
RxClaim OnlyClient hierarchy for utilization management appropriateness and SGM programs
Carrier: 8547
Carrier –Account:
Carrier – Account – Group:
Do the selected clinical programs apply to all members or specific groups of members?
All members Specific groups (specified below)
Please specify details here:CCAI is a medicare Plan that will be using our 2T Template formulary and our standard UM without customizations.
*Note: Not all dosage forms will accumulate across the entire class.
For clients that wish to implement custom UM edit(s) that have already been developed for another line of business, please indicate this within the following sections of this form.-Special Instructions/Notes section below.
-Client Requested-Custom section at the end of each UM edit type area
Within these sections, please indicate the following: [ENTER SPECIFIC XYZ Plan List NAME] for each of the custom edits to be implemented.
Special Instructions/Notes
UM and SGM Auto-Update Selection
UM auto-update
- Auto-update is mandatory for any standard criteria selected by the client
- Auto-update is not available for any custom criteria requested by the client
UM Auto-Update Criteria Selection:Client elects not to receive Criteria, but may request Criteria at any time
SGM auto-update
- Criteria auto-update is mandatory for any standard criteria selected by the client
- Drug auto-update is defined as automatic drug additions or deletions without a new CPM form
- A therapy class is eligible for drug auto-update when all drugs listed in the therapy class are elected and use standard criteria
Client elects to participate in drug auto-update of therapy classes elected on the CPM form
Client elects to participate in drug auto-update of therapy classes elected on the CPM form and the addition of new therapy classes as they become available to SGM
SGM Auto-Update Criteria Selection:Client elects not to receive Criteria, but may request Criteria at any time
RxClaim and Recap Only
UM auto-update definition
"Auto-update" defined as utilization of auto-update for the PA criteria only
Utilization management (UM) program options*
Benefits Effective Date: 01/01/2014
Criteria Type: CVS Caremark Medicare Part D
Client elects to use client-requested/customCriteria for specific identified Clinical Services:♦
Yes No
UM Programs & Appeals / CVS Caremark Admin / CVS Caremark
Entered / Client Admin / Client Entered
Prior Authorization
Quantity Limit with and without post-limit PA
Step Therapy with and without post-step PA
Generic Step Therapy Plans
Prescription Claim Appeals Level One
Prescription Claim Appeals Level Two
(Does Not Apply for Healthcare Marketplace Exchange Plans)
Independent/External Appeals Review (Health Care Reform)
*All programs indicated on this form will apply to all three delivery systems - mail, retail and paper.
♦For clients that wish to implement custom UM edit(s) that have already been developed for another line of business, please indicate this within the following sections of this form.
- Special Instructions/Notes section above.
- Client Requested-Custom section at the end of each UM edit type area which follows.
Prior Authorization Implementation Details
Pre-Implementation
letters produced by: / CVS Caremark
Please submit Member Communications mailing requests through the Aprimo tool (accessible for Sales and Account Services via the “Member Communications” tab in SalesForce.com).
- For questions about member communications mailings or products, please contact
- For questions about Aprimo access, please contact
No letter
Pre-Implementation letters mailed to: Member Provider Member & Provider
* If CVS Caremark is to mail the letters an additional charge of $1.00 per letter will be added
PA Standard Message: “Prior Authorization Required-MD Call CVS Caremark PA phone number below” / PA Custom Message (40 character max):
Quantity Limits Implementation Details
Pre-Implementation
letters produced by: / CVS Caremark
Please submit Member Communications mailing requests through the Aprimo tool (accessible for Sales and Account Services via the “Member Communications” tab in SalesForce.com).
- For questions about member communications mailings or products, please contact
- For questions about Aprimo access, please contact .
No letter
Pre-Implementation letters will be mailed to: Member Provider Member & Provider
* If CVS Caremark is to mail the letters an additional charge of $1.00 per letter will be added
** The duration of 25 days is used for a 30-day fill period and 75 days is used for a 90-day fill period to allow time for refill processing.
The One Month Limits apply to Retail claims; the Three Month Limits apply to Mail Order claims and 90 days supply claims for specific Retail Programs only (such as MChoice).
Quantity Limits Message with no post-limit PA
Quantity Limits Standard Message: “Quantity Limit Exceeded”
Quantity Limits Custom Msg (40 character max):
Quantity Limits Messagewith post-limit PA
Quantity Limits Standard Message:“Qty lmt exceed PA reqrd call CVS Caremark PA phone number below”
Quantity Limits Custom Msg (40 character max):
Step Therapy Implementation Details
Pre-Implementation
letters produced by: / CVS Caremark
Please submit Member Communications mailing requests through the Aprimo tool (accessible for Sales and Account Services via the “Member Communications” tab in SalesForce.com).
- For questions about member communications mailings or products, please contact
- For questions about Aprimo access, please contact
No letter
Pre-Implementation letters will be mailed to: Member Provider Member & Provider
* If CVS Caremark is to mail the letters an additional charge of $1.00 per letter will be added
Standard Post-Step PA Message: “Must meet step, PA required, call CVSCaremark PA phone number below”
Custom Post-Step PA Message (40 character max):
* Grandfathering of plan members allows a member to continue to receive a medication at a determined (it could be the same as in the past or different) copay level without having to meet the step therapy criteria. Grandfathering is implemented to cover medication that has previously been approved by the plan.
RxClaim Only
CVS Caremark Prior Authorization phone number
1-800-294-5979
SGM Program Implementation Choose the SGM Program(s) to apply
Will client be accepting: All Programs or Other (specified in Therapy and Drug List tables)
SGM Program will be implemented as: Exclusive to CVS Caremark Not Exclusive to CVS Caremark
Anticipated SGM Implementation Date (60 days lead time required): 01/01/2014
How long will client grandfather* existing utilizers?
Standard option (up to 180 days) Custom option (greater than 180 days), specified duration
*All members new to therapy will be reviewed prior to first fill.
Medical Benefit Management (MBM) - Oncology Management Solutions (OMS) program
Check here if turning off any SGM Oncology drugs and the client is implementing Medical Benefit Management (MBM) - Oncology Management Solutions (OMS) program.
SGM Internal Client Information
Current PA status: Brand new to CMK (Existing PA with other provider) Existing CMK PA
Existing CMK and New to SGM
Date each medication in SGM has been verified as a covered benefit:
SGM Targeted Mailing Information - only patients new to SGM will receive the targeted mailings
Does the client want to send SGM targeted mailings? Yes No
Is the client sending claims data* for SGM targeted mailings? Yes No
* Claims data must be received 60 days prior to SGM implementation date to ensure SGM plan members receive 30 days advance notice
SGM Case Decision Rules
CVS Caremark will complete an assessment according to the criteria based on the answers to the questions provided from the prescribing physician
1. If participant meets guidelines, CVS Caremark will:
Approve the case and notify the prescribing physician and participant of the approval. (Program Standard)
Complete an assessment and communicate to Client that the plan participant meets guidelines. Client will provide CVS Caremark with an authorization for approval. CVS Caremark will notify the prescribing physician of the approval.
Method of Communication with Health Plan: Web
Resource Communication Contact with Health Plan:
Contact Name: Contact Fax:
Contact Phone: Contact Email:
2. If participant does not meet guidelines, CVS Caremark will:
Send the denial letter to the prescribing physician and participant. (Program Standard)
Send the plan participant assessment and clinical information to the client for medical review requesting approval/denial decision.
Method of Communication with Health Plan: Web
Resource Communication Contact with Health Plan:
Contact Name: Contact Fax:
Contact Phone: Contact Email:
Client will make the decision to approve or deny the request. Client will:
Send the denial or approval letter to the physician and plan participant. Client will communicate approval or denial information
to CVS Caremark.
Communicate the denial or approval information to CVS Caremark. CVS Caremark will send and communicate the approval or denial information to the physician and plan participant
Method of Communication to CVS Caremark: WEB
Are there additional organizational requirements (i.e., time frames) requested for CVS Caremark to follow?
No Yes, please list :
Appeals
Is this an ERISA Client: Yes No
If not ERISA client:
Which state laws apply in regards to appeals: Not Applicable Specify: Medicare
What type of plan does the client have: Church plan Government plan
Caremark Internal Only – UM and SGM
Important Information regarding letter requests.
*Effective 2/1/2011, all standard PA/Appeals/SGM letters will be migrated to the Health Care Reform compliant letters as our standard. For all custom letter requests, please submit the Brand Compliance custom letter along with CPM form through Salesforce.com. Please take appropriate action if your client requires a custom letter.Please note that stand alone PA cases can be submitted through Salesforce.com when NO Benefits action is required.
Does the client have foreign-language members in the
qualifying US counties? List available on MAX. Yes No
If YES, what language: Spanish Tagalog Chinese Navajo
*Please note foreign language translation will be in effect on 1/1/2012.
First Level Appeals
Attention: Healthcare Marketplace Exchange Plans:A single-level, integrated internal appeals process which includes a medical necessity review is applied for all Healthcare Marketplace Exchange clients.
Which clinical programs do First Level appeals apply to: UM SGM UM & SGM