HomeMy WebLinkAboutAgreement - Blue Cross Blue Shield - Self Fund Medical Insurance for CIty Employees for 20191316 COUNTY -CITY BUILDING
227 W.JEFFERSON BOULEVARD
SGl ITH BEND. INDIANA 46601-1 830
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SOUTHCITY OF BEND PETE BUTTIGIEG, MAY
WRKS IB„ / ` i 1
November 13, 2018
Karen Fox
Anthem Blue Cross and Blue Shield
220 Virginia Avenue - IN0201-565
Indianapolis, IN 46204-3632
RE: Agreement
Dear Ms. Fox:
PHONE 574/235-9251
FAx 574/235-9171
The Board of Public Works, at its meeting held on November 13, 2018, approved the above
referenced agreement to administer self -funded medical insurance for City employees for
2019 calendar year in the amounts of $589;162.56 for the Stop Loss Premium, $793,879.80
for Medical Administration Costs and variable prescription costs.
Enclosed please find a copy of the agreement for your records.
If you have any further questions regarding this matter, please call this office at (574) 235-
9251.
Sincerely,
Linda M. Martin, Clerk
Enclosure
cc: Margaret Harsough, Gibson Insurance, 130 S. Main Street, Suite 400, South Bend,
IN 46634
Your Summary of Benefits
City of South Bend - PPO Plan
Blue Access® (PPO)
Effective January 1, 2019
Deductible (Single/Family)
Out -of -Pocket Limit (Single/Family)
Physician Home and Office Services (PCP/SCP)���
Primary Care Physician (PCP)/
Specialty Care Physician (SCP)
Including Office Surgeries and allergy serum:
o allergy injections (PCP and SCP)
o allergy testing
o MRAs, MRIs, PETS, C-Scans, Nuclear
Cardiology Imaging Studies,
non -maternity related Ultrasounds, and
pharmaceutical products
Preventive Care Services
Services include but are not limited to:
Routine Exams, Mammograms, Pelvic Exams, Pap
testing, PSA tests, Immunizations', Annual diabetic eye
exam, Vision and Hearing screenings
o Physician Home and Office Visits (PCP/SCP)
o Other Outpatient Services @
Hospital/Alternative Care Facility
Emergency and Urgent Care
Emergency Room Services
o facility/other covered services
(copayment waived if admitted)
Urgent Care Center Services
o MRAs, MRIs, PETS, C-Scans, Nuclear
Cardiology Imaging Studies,
non -maternity related Ultrasounds, and
pharmaceutical products
o Allergy injections
o Allergy testing
Inpatient and Outpatient Professional Services
Include, but are not limited to:
o Medical Care visits (1 per day), Intensive
Medical Care, Concurrent Care, Consultations,
Surgery and administration of general
anesthesia and Newborn exams
Blue 11.0
$1,000/$3,000 $2,000/$6,000
�
_... /
$4,000/$8,000 $7,5001$16,500
$301$60 40%
$5 40%
20% 40%
20% 40%
NCS 40%
NCS 40%
$200/20% I $200120%
$75 40%
20% 40%
$5 40%
20% 11 J 40%
20% 40%
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Your Summary of Benefits
Inpatient Facility Services (Network/Non-Network
combined) Unlimited days except for:
0 60 days Network/Non-Network combined
for physical medicine/rehab (limit includes
Day Rehabilitation Therapy Services on an
outpatient basis)
o y d nursing facility
Outpatient Surgery Hospital/Alternative Care Facility
o Surgery and administration of general anesthesia
Other Outpatient Services (including but not limited to):
o Non Surgical Outpatient Services
For example: MRIs, C-Scans,
Chemotherapy, Ultrasounds and
other diagnostic outpatient services.
o Home Care Services
(Network/Non-Network combined)
90 visits (excludes IV Therapy)
o Durable Medical Equipment and Orthotics
o Prosthetic Devices
o Prosthetic Limbs
o Physical Medicine Therapy Day
Rehabilitation programs
o Hospice Care
o Ambulance Services
.,.. ..........
..... _ _... .. ... ..........
Outpatient Therapy Services
(Combined Network & Non -Network limits apply)
o Physician Home and Office Visits (PCP/SCP)
o Other Outpatient Services @ Hospital/Alternative
Care Facility
Limits apply to:
o Physical therapy: 60 visits
o Occupational therapy: 60 visits
o Manipulation therapy: 12 visits
o Speech therapy: 40 visits
o Cardiac Rehabilitation: Unlimited
o Pulmonary Rehabilitation: Unlimited
Accidental Dental: $3,000 limit per occurrence
(Network and Non -network combined)
20% % 40%
20% N 40%
20% 140%
NCS NCS
20% 20%
$30/$60 40%
20% 40%
Copayments/Coinsurance
based on setting where
covered services are
received
40%
Your Summary of Benefits
Behavioral Health Services
Mental Illness and Substance Abusez:
7o-�-w7l)%
o Inpatient Facility Services
o Inpatient Professional Services
20%
o Physician Home and Office Visits (PCP/SCP)
$30$30
o Other Outpatient Services, Outpatient Facility
20%
@ Hospital/Alternative Care Facility,
Outpatient Professional
Human Organ and Tissue Transplants3
NCS
50%-
o Acquisition and transplant procedures,
harvest and storacge®
Prescription Drug Options:
Anthem National Drug List
Network Tier structure equals 11213
(and 4, if applicable)
Tier 1: 20%
50%, min $604
o Network Retail Pharmacies:
Tier 2: 30%
(30-day supply)
Tier 3: 40%
Includes diabetic test strip
All Tiers: $250 maximum per
prescription
o Home Delivery Service:
Tier 1: 20%
Not covered
(90-day supply)
Tier 2: 30%
Includes diabetic test strip
Tier 3: 40%
All Tiers: $750 maximum per
prescription
$2,600/$5,200
$5,200/$10,400
o Calendar Year Out of Pocket Maximum:
Member may be responsible for additional cost when not
selecting the available generic drug.
Medicare Rx • Wrap
Lifetime Maximum
Medical
Unlimited
Unlimited
Surgical Treatment of Morbid Obesity
Not covered
Not covered
iwwa.
o All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum (excluding Non -Network
Human Organ and Tissue Transplant (HOTT) Services)
o Deductible(s) apply to covered medical services listed with a percentage (%) coinsurance, including 0%. However, the deductible does not apply
to Emergency Room Services where a copayment and coinsurance applies and may not apply to some Behavioral Health services where
coinsurance applies.
o Dependent age: to end of the month which the child attains age 26.
o Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OB/GYNs and Geriatrics or any other
Network Provider as allowed by the plan.
o Ambulance Non -network non -emergency use limited to $50,000 per benefit period.
o NCS (No Cost Share) means no deductible/copayment/coinsurance up to the maximum allowable amount.
Your Summary of Benefits
O PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics,
obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan.
O SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
O Live Health Online (LHO) is covered at the PCP costshare.
O Certain diabetic and asthmatic supplies, except diabetic test strips, have no deductible/copayment/coinsurance up to the maximum allowable amount
at network pharmacies,
o Benefit period = calendar year
O Prosthetic limbs are unlimited and do not apply to the Plan Lifetime Maximum.
O Mammograms (Diagnostic) are no copayment/coinsurance in Network office and outpatient facility settings.
O Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity.
O Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician
visits are no deductible/coinsurance up to the maximum allowable amount.
O Private Duty Nursing — limited to 82 visits/Calendar Year and 164 visits/lifetime.
Elective abortions not covered unless otherwise noted in your Certificate of Coverage..
1 These covered services are not subject to the deductible/copayment if you have a flat dollar oopayment and if rendered without an office visit.
2 We encourage you to review the Schedule of Benefits for limitations.
3 Kidney and Comea are treated the same as any other illness and subject to the medical benefits.
4 Rx non -network diabeticlasthmatic supplies not covered except diabetic test strips.
Precertif!cation:
Members are encouraged to always obtain prior approval when using non -network providers. Precertification will help the member know if the services are considered not
medically necessary.
Pre•exlsting Excluslon Period: none
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform
laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor
and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
This benefit overview is for illustrative purposes and some content may be pending Indiana Department of Insurance approval.
This summary of benefits is intended to be a brief outline of coverage. The enfire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and
Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.
By signing this Summary of Benefits, I agree to the benefits for the product selected as of the effective date indicated.
Your Summary of Benefits
City of South Bend — HRA Plan
Lumenos Health Reimbursement Accounts
Effective January, 1.. 2019
Employer Health Reimbursement Account
Contribution:
Single: $500 Family: $1,000
Deductible (Embedded)
Single: $2,500
The single deductible does apply to family covera_11111ge
.. .
Family: $5,000
Employee Bridge Amount*
Single: $2,000
........... _-..
Family: $4,000
—
Out -of -Pocket Limit
Single: $5,000
Family $10 000
Physician Home and Office Services
20%
o Including Office Surgeries, allergy serum,
allergy injections and allergy testing
Preventive Care Services
NCS
o Routine medical exams, Mammograms, Pelvic
Exams, Pap testing, PSA tests, Immunizations,
Annual diabetic eye exam, Hearing screenings
and Vision screenings which are limited to
Screening tests (i.e. Snellen eye chart) and
Ocular Photo screening
Emergency and Urgent Care
o Emergency Room Services @ Hospital 20%
(facility/other covered services)
(copayment waived if admitted)
o Urgent Care Center Services 20%
Inpatient and Outpatient Professional Services 20%
Include but are not limited to:
o Medical Care visits (1 per day), Intensive
Medical Care, Concurrent Care, Consultations,
Surgery and administration of general
anesthesia and Newborn exams
Inpatient Facility Services (Network/Non-Network 20%
combined) Unlimited days except for:
0 60 days for physical medicine/rehab
(limit includes Day Rehabilitation Therapy
Services on an outpatient basis)
0 100 days for skilled nursing facility
Blue 11.0
An e;,
B1ueCross BlueShield m
Single: $5,000
Family: $10,000
Single: $10,000
Family $20 000
50%
50%
20%
50%
50%
50%
Outpatient Surgery Hospital/Alternative Care Facility 20% 50%
o Surgery and administration of
_ general anesthesia
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Your ummary of Benefits
4 tl
81411
4
Other Outpatient Services
20%
50%
including but not limited to:
o Non Surgical Outpatient Services
For example: MRIs, C-Scans,
Chemotherapy, Ultrasounds and
other diagnostic outpatient services,
o Home Care Services 90 visits
(excludes IV Therapy) (Network/Non-network
combined)
o Durable Medical Equipment, Orthotics
and Prosthetics
o Physical Medicine Therapy Day
Rehabilitation programs
o Hospice Care
20%
20%
o Ambulance Services
__.
20%
20%
__. _ .....m..
Accidental Dental Services $3,000 per accident
n .........
20%
50%
(Network and Non -network combined
Outpatient Therapy Services
(Combined Network & Non -Network limits apply)
o Physician Home and Office Visits
20%
50%
o Other Outpatient Services @ Hospital/Alternative
20%
50%
Care Facility
Limits apply to:
o Cardiac Rehabilitation: Unlimited
o Pulmonary Rehabilitation: Unlimited
o Physical therapy: 60 visits
o Occupational therapy: 60 visits
o Manipulation therapy: 12 visits
o Speech therapy: 40 visits
Behavioral Health Services:
Benefits provided in
50%
Mental Illness and Substance Abuse'
accordance with Federal
o Inpatient Facility Services
Mental Health Parity
o Physician Home and Office Visits
o Other Outpatient Services @ Hospital/Alternative
Care Facility
Human Organ and Tissue Transplants
o Acquisition and transplant procedures,
20%
50%
harvest and storage.
Your Summary of Benefits
Prescription Drugs: Anthem National Dr"77777
o Network Retail Pharmacies:
(30-day supply)
Includes diabetic test strip
o Home Delivery Service: 20% Not covered
(90-day supply)
Includes diabetic test strip
- Specialty medications are limited up to a 30 day supply
regardless of whether they are retail or mail service
- Member may be responsible for additional cost when
not selecting the available generic drug
Medicare Rx • Wrap
Notes:
0 All medical and drug cost shares, deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding Non -Network
Human Organ and Tissue Transplant (HOTT) Services.
o Deductible(s) apply to covered services listed with a percentage (%) coinsurance, including 0%.
o Deductible applies to all prescription drug expenses for Rx plans. Once the deductible is met the appropriate copaymenU coinsurance applies.
Copayments/coinsurance accumulate to the Medical OOP max. Once the Medical OOP max is met, no additional cost share applies.
o Once the family deductible is satisfied by either one member or all members collectively, then the additional percentage coinsurance will be required
before the family out-of-pocket is satisfied. Does not apply to embedded deductible plans.
0 Network and Non -network Deductible, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward
each other.
o Dependent Age: to end of the month which the child attains age 26
0 0% means no coinsurance up to the maximum allowable amount. However, when choosing a Non -network provider, the member is responsible for any
balance due after the plan payment.
I No Cost Share (NCS): No deductible/copayment/coinsuran ce up to the maximum allowable amount.
o Ambulance Non -network non -emergency use limited to $50,000 per benefit period.
o Live Health Online (LHO) is covered at the PCP cost share.
o Benefit period = calendar year
o The maximum allowable HRA rollover contribution amount will be either three times your employer health account contribution or unlimited.
0 For employers that select calendar year benefits and have an effective date other than January 1, the Employees HRA Employer Contribution will be
prorated based upon the number of months enrolled in the plan.
0 Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity.
0 Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are
covered.
o Private Duty Nursing - limited to 82 visits/Calendar Year and 164 visits/lifetime
0 Wigs: limit 1 (one) maximum for wigs due to cancer diagnosis per benefit
o Elective abortions not covered unless otherwise noted in your Certificate of Coverage.
' We encourage you to refer to the Schedule of Benefits for limitations.
z Rx non -network diabeticlasthmatic supplies not covered except diabetic test strips.
Meets Indiana state mandated effective 71112008.
"Bridge is not an insurance loom and does not a,ppear in the Certificate. HRA hinds can be used for covered services under the benefit plan. Bridge amounts may be reduced
if incentives are eamed and by Contribution Rol ever amounts in subsequent years. Employer must fund in order to be considered a Health Reimbursoment Account.
Employer most continue to fund for the entire year at the HRA level indicated.
Precertiflcatlon:
Members are encouraged to always obtain prior approval when using non -network providers. Precertification will help the member know if the services are considered not
medically necessary.
Pre-existing Exclusion Period: None
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform
laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor
and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
Your Summary of Benefits
This benefit overview is for illustrative purposes and some content maybe pending Indiana Department of Insurance approval
This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate
and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.
By signing this Summary of Benefits, I agree to the benefits for the product selected as of the effective date indicated.
e.
City of South Bend
Group ID
00103525
Summary
of Costs for the Renewal Contract Year from 01/01/2019 through 12/31/2019
Current Subscribers
Per Subscriber Per Month Cost
FIXED COSTS:
Med/RX
Dent Vis
Med/Rx
Dent
_
Vis
d.......�
Grand Total
Admin Fee / Network / UM
1,067
0
0
$59.40
$0.00
$0.00
$59.40
Admin EnhClinPkg
1,067
0
0
$5.05
$0.00
$0.00
$5.05
Admin ActWise HRA
108
0
0
$2.75
$0.00
$0.00
$2.75
Broker's Commission
0
0
0
$0.00
$0.00
$0.00
$0.00
Specific SL Premium
1,067
0
0
$48.04
$0.00
$0.00
$48.04
Aggregate SL Premium
0
0
0
$0.00
$0.00
$0.00
$0.00
Total Fixed Costs (Illustrative)
1,067
0
0
$112.77
$0.00
$0.00
$112.77
CLAIMS EXPENSE:
Expected Claims Liability
1,067
0
0
$1,018.57
$0.00
$0.00
$1,018.57
Maximum Claims Liability
1,067
0
0
N/A
N/A
N/A
N/A
TOTALCOST:
Estimated Annual Cost
Expected
Med/Rx
,........
Dent
Vls
.,...
Grand Total
Fixed Cost
$1,443,886
$0
$0
$1,443,886
Expected Claims Expense
$13,041,770
$0
$0
$13,041,770
Total Expected Cost
$14,485,656
$0
$0
$14 485,656
Maximum
Fixed Cost
$1,443,886
$0
$0
$1,443,886
Maximum Claims Expense
N/A
N/A
N/A
N/A
Total Expected Maximum Cost
N/A
N/A
N/A
N/A
Renewal Contract is ASO / SSL / No ASL on a Paid basis
Renewal Specific Stop Loss Limit is $300,000 on a Per Member basis with Immediate Reimbursement and coverage applies to Medical; HOTr, MH/SUD; Rx;
Aggregate Stop Loss does not apply
Stop Loss Premium does not include broker commission
Specific Stop Loss Maximum: Unlimited;
This renewal includes EPHC fees, Non -Network and Traditional Savings fees, Rx Ancillary fees, and Program Integrity fees.
Anthem Health and Wellness Programs: Surgical Quality and Safety Management Program $300.00 per occurrence;
Signature and Title Date
Plan Annual Costs illustrated above are based on current enrollment
16143 10/23/2018 9:26 AM
,. South Bend
This is a summary of the guarantees we offer for our prescription drug benefit
Pharmacy Pricing Guarantees
�1]£T
ixs 0 i'{ IMc 201;IJ
J iri 2020 h a, 020
J) rl 20 f) 1
NM'1t oIrk
_..
Brand discount off AkN[l �
®..... ,
AWIII'l minus 18.00%
AWP minus 18.50%
AWP minus 18.50%
IBrnuurl duspreir�r!,fng fee Iroeu- 1=fur
f , 90
$0.65
$0.65
Generic discount % off AWP
AWP minus 80.00%
AWP u°°61niius 80.50%
AWP minus 81.00%
Generic dispensing fee per Rx
$0.90
$0.65
$0.65
The National Plus Pharmacy Network is our broadest retail network option with over 70,000
participating retail pharmacies, including all major chains.
�'{SIIIiE''I'/fy £ r'ilfaffl7;l"''/
Brand discount % off AWP
Brand dispensing fee per Rx
Generic discount nt % off AWP
Generic dispensing fee per Rx
71,111i1�1 r,Yi,r. %l£1'3
AWP minus 26.00%
$0.00
AWP minus 84 00%
$0.00
ari ,?Vf) 19 ,c 2020
AWP minus 26.50%
$0.00
AWP minus 84.50%
$0.00
ri , 02' Uef' nr''C1'r''
AWP minus 26.50%
$0.00
AWP minus 85.00%
$0.00
Home Delivery Choice: Through this program, members have the option of filling their maintenance
medications through the home delivery pharmacy. After a predetermined number of fills at the retail
pharmacy, members must make a choice of whether to switch to home delivery or continue obtaining
the medication through the retail pharmacy. Members must notify the home delivery pharmacy of their
choice. Members receive initial and reminder letters and phone calls to inform them of the program, the
benefits they receive and to help them with making their decision. If City of South Bend implements and
maintains Home Delivery Choice program across all benefits, Mail Order Generic discount will increase
by 0.50% upon implementation of the program.
�,ti r,i �It i:.£r Gar rrUi`ri r,�u r;�r� „rkl� Jun 201 ;7er, 20'1it J,�n 2020 0 o '202 3 Jin 2021 Dec 2021
_ _ ............ ............ .
Overall discount ! off AWPAWP minus 17.00% AWP minus 17.50% AWP minus 17.5�00%
Overall dispensing fee per Rx 0.0 $0.00 $0.00
Prescription Drug Minimum Rebate Guarantee
National Formulary
Our standard and broadest formulary offering is the Anthem National Drug List. This formulary includes
brand -name and generic prescription medications selected through our P&T review process. We chose
medications based on safety, effectiveness and value. The National Drug List includes 98.5% of
prescription medications available in the market.
Aritham Natjonal Formulary Jan 2019 - Dec 2019 Jan 2020 - Dec 2020 Jan 2021 - Doc, 2021
Retail (includes Specialty) Per $107.42 $152.59 $167.47
Brand Script
Home Delivery (includes $1,219.09 $1,733.64 $1,965.43
Specialty) Per Brand Script
We are passing through 100% of the actual rebates Anthem receives to the client, subject to the
minimum per brand script amounts indicated above.
Anthem may receive and retain administrative fees from our pharmacy vendor or directly from
pharmaceutical manufacturers.
summary of our guarantees
This is a summary of the guarantees we offer for our prescription drug benefit. It is not a legal contract.
If this summary conflicts with the Administrative Services Agreement, the Administrative Services
Agreement controls.
APPAQVID
of INJk"
X-3-3
Signature Date
All of the pharmacy guarantees listed on the previous page are effective January 1, 2019, for a term of
3 years, and the following apply:
We can revise our price quote or alter the terms of the guarantees if one of the following
occurs:
The client does not notify Anthem of the offer acceptance 45 days prior to the effective
date.
The client does not implement the recommended clinical and cost -of -care management
programs that are part of the Plan.
The client does not adopt our formulary.
• A change in the proportionate mix of the client's retail and home delivery prescription
drug claims of more than 10%.
• A change in pharmacy utilization patterns of more than 10%.
• A change results in Anthem no longer being the exclusive source of drug rebates for the
client.
• Anthem is no longer the sole administrator for the pharmacy benefit portion of client's
Plan.
• The client has an onsite pharmacy with 340b designation or any such designation where
the pharmacy receives upfront pricing discounts from pharmaceutical manufacturers,
which was not disclosed or known by Anthem as of the effective date of the ASO
Agreement.
o Any excess achieved in a pharmacy financial guarantee will be used to make up for, and
offset, a shortfall in other pharmacy financial guarantees.
o Network guarantees will be calculated on the total eligible claim paid claims.
o Our guarantees exclude the following claims: Prescriptions filled in Massachusetts, Alaska,
Hawaii, or Puerto Rico, or filled in any state which imposes some form of Most Favored
Nations limitations on pharmacy reimbursement; Vaccines; Prescriptions filled through the
Employers on -site pharmacy; Over-the-counter drugs; Dispense As Written Claims; Drugs
subject to patent litigation; Government Reimbursement Claims.
o If there are changes in the AWP reporting source or if there are changes in how AWP is
calculated, including changes in the mark-up factor used to calculate AWP, the terms of any
financial relationship between the parties that relate to AWP will be modified.
o Our formulary will be provided to members and providers.
o Guarantees apply to commercial claims only. Medicare EGWP claims are excluded from all
guarantees.
o Guarantees applies only as long as there are at least 25,000 Annualized Adjusted
Prescription Drug Claims.
o As a portion of our reasonable compensation for services provided, we will retain the
difference, if any, between the invoiced amount to the employer and the amount paid to the
PBM for prescription drugs dispensed to members.
o The client must use Anthem recommended formulary to be eligible for rebates, whether the
rebates are paid or applied as a credit. Pricing guarantees do not apply to claims processed
through staff model/hospital pharmacies where the pharmacy, most likely, has its own
manufacturer contracts (rebate or purchase discounts), or through pharmacies that
participate in the Federal government pharmaceutical purchasing program.
Our guarantees will not apply if one of the following happens:
o A change to the Plan benefits that result in a substantial change in the services to be
performed by Anthem.
o There is no executed Administrative Services Agreement on file.
o Circumstances beyond our control including but not limited to any act of God, civil riot,
floods, fire, acts of terrorists, acts of war or power outages that delay our performance or
that of our vendors.
o The client terminates the Agreement before the end of a performance period, or we
terminate it because of non-payment.
o The client terminates the pharmacy portion of the Plan. Should the client terminate
Pharmacy Services during the Agreement Period for reasons other than for cause in
accordance with this Agreement, client shall pay Anthem an early termination fee in an
amount equal to $3.84 PCPM multiplied by the monthly average of the six months of
enrollment prior to the effective date of termination multiplied by the number of months
remaining in the contract term. Notice of such early termination shall be provided in writing
ninety (90) days in advance of the termination date.
o The client terminates participation in particular programs tied to performance guarantee(s)
prior to completion of the measurement period associated with performance guarantee.
Our Prescription Drug Plano Pro r&rns and Services
We offer a comprehensive suite of trend and integrated health management programs and
services. Below is a list, by product, of the programs and services that are available. This list
is not all inclusive and may change as we update our offering to meet the needs of the
marketplace.
Account management
Included
Banking
Included
Electronic and paper claims processing
Custom Basis
FSA feeds
Included
Implementation services
Included
per claim
Paper claims/member submitted claims processing
ssing
occurrence.
Plan design strategy and consultation
Included
medical/pharmacy Sin le
g ID cards
Included
Standard communication materials
Standard coordination of benefits — reject for primary carrier
Network audits and recoveries (desk and onsite)
On -site pharmacy services
Included
Included
Included
$2.50 per ons,ite
pharmacy claim
Pharmacy help desk with toll -free number
Included
Pharmacy network management
Included
Pharmacy reimbursement
included
Benefit education (includes home delivery promotion)
Included
Home Delivery Education program
....... ..... -
Included
Home Delivery Choice program
Included
Home Delivery Complete program
Included
Home delivery call center with toll -free number
Included
Home delivery claims processing
Included
Home delivery regular shipping and handling
Included
Annual strategic planning with quarterly reviews
Included
Centralized administration for payment of claim and administration fees
Included
. . .... . . . .. . ..... . .........
Designated pharmacy account team support, including Pharmacy Account
Manager, Pharmacy Program Manager (clinical), Pharmacy Services
Included
Coordinator
Telephonic tra i ni n g fo r access to online systems)
Included
Customer service for members with toll -free number, to include language
Included
translation services
Medical/pharmacy customer service call center with toll -free number
Included
e-Services for Prescriptions: Intuitive and easy to navigate
Included
Health and wellness news and articles via WebMD Online drug list and
Included
searchable formulary
Language translation services (EOBs)
Included
Online .......�__ ._.....�....___..�_�_,.__..d�_..�. _.......... __ a_.._...� . ......._. .. ..ww _�.... _
explanation of benefits Included
Online health improvement� � � � � tools and programs Included
Pharmacy look -up Included
Pharmacy resources — request a prior authorization, view drug interaction
data and access all forms Plans and benefits additional information —
Included
submitting new prescriptions, saving money with home delivery, educational
and pharmacy news
Plans and benefits additional information — submitting new prescriptions,
saving money with home delivery, educational and pharmacy news
Refill a prescription
Included
Savings center — compare costs to switch from retail to home delivery
Included
Search and price a medicine — search drugs by name, therapeutic class or
Included
subclass; compare costs and drug details, including price by pharmacy
Secure member message center
Included
Additional miscellaneous Internet services — view coverage and copayments,
Included
obtain an ID card, access drug and health guide
Administrative Prior Authorization program — non -clinical, losVstolen
Included
overrides, vacation supplies
Clinical Prior Authorization program
$55 per PA
This review focuses mainly on drugs that may have risk of serious side effects
or dangerous drug interactions, high potential for incorrect use or abuse,
better alternatives that may cost less, or restrictions for use with very specific
conditions.
_
Clinical Pharmacy Review — physician review
Included ��...�m ...
Certain medications need a higher level of review than a Clinical Prior
Authorization and additional information from the prescriber.
Step Therapy � _._...._.�._.�._�_.�. _..__._...__...,.�a._. �.........�.__....__ _____�.
-$0.30 per script
Step therapy requires the member to use one medication before benefits for
the use of another medication can be authorized. Step therapy ensures
members have previously used first -line therapies or have risk factors making
the prescribed products inappropriate.
Quantity Limits and Dose Optimization
$0.55 per script
Quantity limits guard against high doses and excessive utilization based on
either doses exceeding the FDA or manufacturer recommended maximum
daily doses or limiting short-term medications to a certain number of fills over
a defined period of time.
Concurrent Drug Utilization Review programs �
p g
Included
�
This program includes real-time member health and safety protocols designed
to monitor and screen each claim against the member's integrated
f
prescription profile, including all home delivery, specialty and retail
prescriptions processed through the prescription benefit plan.
Pharmacy Gaps in Care Messaging programs, including'. � $0.25 per script
Medication Review
o Personalized member information related to pharmacy gaps in care
including appropriate use, medication compliance, safety, cost
savings on generics and formulary alternatives.
o Select Cost -of -Care messages sent via a standalone
communication:
Generic Select: Members sent information on selected brand
drugs where a generic is available and receive waived copay
for first fill of Generic Select drug both at home delivery and
retail.
Half Tablet: Members sent information on selected drugs
eligible for half of the copay when they fill half as many tablets
at double the strength and cut the'tablets.
Patient Highlights
o Physicians receive personalized, actionable information related to
appropriate use, medication compliance and safety to help address
pharmacy related gaps in care.
o Appropriate use and compliance programs focus on disease states
such as asthma, COPD, depression, diabetes, high cholesterol and
hypertension.
o Safety programs including identification of polypharmacy and high -
dose alerts.
o Personalized, actionable information related to the members use of
controlled substances.
Prospective Drug Utilization Review programs Included
Cost -of -Care programs: � Included
o Formulary management — outcomes -based formulary
Generic Drug Management: � Included
o Preferred Generics — members pay brand copay plus the cost
difference when a generic is available but a brand is selected
o First -Time Generics — letters to members when there is a new (first -
in -class) generic available in a therapeutic class
Retail -to -Home Delivery member outreach programs Q Included
Vaccine Program Fee
R 1),oihng , er uC,'es
$2.50 per vaccine
claim
Clinical savings reports
Specialty pharmacy regular shipping and handling
Therapy -specific counseling
and P1,091TIMS
Custom/Ad-hoc requests
Medicare services
Custom/Ad hoc letters
I Included
Included
Included
Included
Included
Included
Included
Included
First 20 hours
included at no charge.
After 20 hours per
year, the charge is
$150 per hour of time
needed to generate a
custom or ad -hoc
report.
Available upon
request.
$1.00 per letter.
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date 11 /5/2018
Name Kvra Clark
Department Human Capital&
Inclusion
BPW Date 11/13/2018 Phone Extension 7500
Re wired Prior to Submittal to Board
Legal ® Attorney Name Danielle Campbell
Controller Controller review is required for all Contracts $5,000.00 or more and
greater than one year in length per the City Purchasing Policy
Purchasing
Check the
Z Agreement
Z Professional Services
❑ Bid Opening
❑ Quote Opening
Change Order No.
❑ Ease/Encroach.
F] Other:
iroriate Item Tyke - fo
❑ Contract
El Resolution
0 Bid Award
El Quote Award
F-I C/O & PCA No.
Traffic Control
for All Submissions
Proposal
❑ Req. to Advertise
❑ PCA
Addendum
❑ Title Sheet
__Required Information
-
Company or Vendor Name ANTHEM
New Vendor ❑ Yes Z No ❑ If Yes, Approved by Purchasing
MBE/WBE Contractor ❑ MBE F WBE
MBE/WBE Contractor Requested ® No F Yes Name of Company
Project Name Administrator Self -Funded Medical Insurance for City employees
Project Number
_._................_w._ ��.�.. .... ......_.. ,�. w_ ���� ........ .� _..............
Funding Source Health Insurance Fund
Account No. 711-0401-671-31-06
Amount Stop Loss Premium: $589,162.56
Medical Administration Costs: $793,879.80
Prescription: Varies —see Pharmacy Pricing Guarantees
.._...._.....__
e a .......� .....6 mm_
Terms of Contract Threement covers the 2019 calendar. year�mmmmmmmm w_w
Purpose/Description Anthem administers the Cit 's self -funded health insurance medical
and prescription) program and serves as the Cit 's stop loss carrier.
Required Contractor's Certification Form Attached (Non -
Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.)
._.. Re pyre Far
_.. ._m.
an e Orders
Amount of El Increase $
Decrease $
Previous Amount
Current Percent of Change
New Amount
Total Percent of Change:
Dispersal After Approval
Copy Original
® ❑ _Kyra wClark, Ben Dougherty, Tierra Davis
❑ ❑ _ ......