Medicare Part D Utilization Management - 2014
All services offered will be provided byCVS Caremark Part D Services, LLC.
ON the Cover Page (Client’s E-MAIL notification is required with all UM submissions)Client Name: / CCAI / FAF ID: / 8547
This document contains proprietary information of CVS Caremark Part D Services, LLC.and may not be used for any purpose other than to evaluate or establish a relationship with CVS Caremark Part D Services, LLC., nor may it be duplicated or disclosed for any other purpose without prior written authorization from CVS Caremark Part D Services, LLC. By executing and delivering this document, the Plan Sponsor agrees that it has received CVS Caremark Part D Services, LLC.’s Prescription Benefit Services Agreement or Addendum, as appropriate, and acknowledges that CVS Caremark Part D Services, LLC.shall provide services in accordance with the terms and conditions of such Agreement or Addendum, including without limitation its terms regarding payment for such services, until a final Agreement/Addendum is executed by the parties. While Plan Sponsor shall have final approval over prior authorization or formulary exception (“PA/FE”) criteria, CVS Caremark Part D Services, LLC.may from time to time propose revisions to the criteria. If Plan Sponsor does not approve of such proposed revisions, it may terminate the Agreement of the PA/FE services or adopt a customized criteria for a mutually agreed upon fee. Plan Sponsor shall be deemed to have approved any proposed revisions to the criteria unless it notifies CVS Caremark Part D Services, LLC.in writing of its objections.
I have reviewed the attached documentation and conclude all information to be correct
Client (attach e-mail notification to client) / Date: 08/26/2013
Client (Print): Ellen Dooley
CA (Print): Lori Smith / SAE (Print): Charles Hughes
AM (Print): Susan Edwards / Implementation Specialist (Print): Craig Anderson
BRM (Print): Renee Ramage
Utilization Management Programs Options and Pricing(Submission includes the following, check all that apply)
All programs indicated on this form will apply to all three delivery systems - MOR-mail, POS-retail, and PCL-paper.
If the Client is to administer the program & Caremark is to enter it, consult with underwriting and change the cost as required.
If the Client is to administer & enter the program, change the cost as required.
UM Programs & Appeals / Caremark Admin / Caremark Entered / Client Admin / Client Entered
Prior Authorization NonSpecialty (Standard)
Prior Authorization Specialty (Standard)
Prior Authorization (Non-Standard/Custom)
Drug Limit (Standard)
Drug Limit (Non-Standard/Custom)
Step Therapy (Standard)
Step Therapy (Standard/Custom)
Coverage Determination
Redetermination – NonClinical (or Level One Appeal)
Redetermination – Clinical (or Level One Appeal)
Total Number of Pages Submitted
Attachments
Signed Custom Criteria
Appeals/ERISA (As required)
Utilize Auto PA Criteria Update Criteria Only Decline
PA, Administrative PA, Quantity limit, Step Therapy Implementation Messaging:
Standard (see below)
Quantity Limit Exceeded
PA Required-MD Call 1-855-344-0930
Must Meet Step, PA reqr 1-855-344-0930 (prerequisite drugs may be inserted)
BvD PA Req Providers call 1-855-344-0930
Custom (40 character max): __
______
Prior Authorization duration of approval 10 years for select group of drugs as approved by CVSCMK Medical Affairs.
Accept
Decline
UM Templates
Standard / Template / Template with modifications (use the custom section )
Expanded / Template / Template with modifications (use the custom section )
Custom (use custom sections on the UM form)
Note--Long Term Care: Administrative PA (B vs D) for nebulizer solutions and infusion pump drugs do not apply to LTC members.
Total Number of Attachments
Client Detail
Client Name: CCAI
Market Segment: EmployerGovernmentHealth PlanHealth Plan/MedicaidMedicarePuerto RicoTaft-HartleyTPA / State: IL
Client Contact (Print): Ellen Dooley
[RxClaim]Carrier(s): 8547
Customer Care Provided by: Caremark Client / Customer Care Phone Number: 1-888-232-8479
If PA does not apply to ALL Accounts, Groups, or Plans, specify who it will apply to:
Utilization Management Programs Implementation
Requested PA Call Center Effective Date:01/01/2014
Actual PA CallCenter Effective Date: (For PA department use only)
(Actual PA Call Center Effective date is the date the PA department will be able to handle calls and must precede mailing of PA pre-implementation letters.)
(The Requested PA Call Center Effective Date is subject to change by the PA department. If the actual date varies from the requested date, the requested date will be deleted.) (NormalPA charges will apply to any PA that is worked before the PA Call Center effective date.)
(Standard lead time is 30 days from receipt of signed documentation.)
Benefits Effective Date:01/01/2014 The Benefit Effective Date should never come before the PA Call Center Effective Date. This is the date that PA coding is complete and messaging is active on the adjudication platform.
Total Plan Participants:Please provide the Total Plan Participants number if known, this is used to project PA call volume.
UM Completion Date:
CUSTOM - Special Instructions/Notes/Clarifications
If your client uses custom messaging (including phone number), please provide this information on page #2.
LIST ANY CHANGES FROM TEMPLATE – list any template UM that will not be used or will need to be changed
CA will forward above pages with a signed & dated UM Signature Page to:
Mail to Code 512 (PA Area)or
Fax to 1-866-303-1654and
E-mail to AM to submit through salesforce.com (SFDC) for both MedHOK and CAS requests.
Appeals Implementation (Required for every plan – PA cannot go live without this information)
Coverage Determination and Redetermination (Appeal Level One) Processed by:
(Complete only one of the following 2 sections. Note- the party processing coverage determination must also process redetermination)
Caremark (Note: Caremark will process all appeal requests – not just for the UM programs on this form)
A signed Prescription Claim Appeals Addendumis required before the program can be implemented.
Contact Legal for the current version of thePrescription Claim Appeals Addendum
Has the Addendum process been initiated with Legal?
Yes No
-OR-
Coverage Determination and Redetermination (Appeal Level One) Processed by:(Complete only one of the following 2 sections. Note- the party processing coverage determination must also process redetermination)
Client or Other Contracted Agent
Appeals Contact:
PhonePhone Number:
FaxFax Number:
LetterAddress:.
Note: Second Level Appeals are processed by Maximus
1
Proprietary and ConfidentialRevised 8/01/2013v