HomeMy WebLinkAbout20221896.tiffRESOLUTION
RE: APPROVE POINT SOLUTIONS MANAGEMENT AMENDMENT #1 AND VENDOR
ELECTION FORM, AND AUTHORIZE CHAIR PRO-TEM TO SIGN - AETNA LIFE
INSURANCE COMPANY
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with Point Solutions Management Amendment
#1 and a Vendor Election Form between the County of Weld, State of Colorado, by and through
the Board of County Commissioners of Weld County, on behalf of the Department of Human
Resources, and Aetna Life Insurance Company, commencing October 1, 2022, with further terms
and conditions being as stated in said amendment and form, and
WHEREAS, after review, the Board deems it advisable to approve said amendment and
form, copies of which are attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that Point Solutions Management Amendment #1 and the Vendor Election
Form between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Human Resources, and Aetna
Life Insurance Company, be, and hereby are, approved.
BE IT FURTHER RESOLVED by the Board that the Chair Pro-Tem be, and hereby is,
authorized to sign said amendment and form.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 6th day of July, A.D., 2022.
BO D OF COUNTY COMMISSIONERS
W JLD COUI ITY, COLORADO
ATTEST: a. 4J G� ad,„, ,1
Weld County Clerk to the Board
BY: yRSII"
De ty Clerk to the‘Board
AP
Count ttorney
Date of signature: 1 - - as
on Saine
otttt K. James, Chair
eeman, Pro-Te
2022-1896
PE0033
cc :PE(SS/SDF) F L(cP/aa)
41/21/,22
BOARD OF COUNTY COMMISSIONERS
PASS -AROUND REVIEW
PASS -AROUND TITLE: Prudent Rx - Health Plan Pharmacy - Formulary Updates
DEPARTMENT: Human Resources DATE: 06/27/2022
PERSON REQUESTING: Staci Datteri-Frey / Jill Scott
Brief description of the problem/issue:
By implementing the Prudent Rx formulary change to our health plan, the County is to experience a
cost -savings to this portion of our health insurance plan costs, specifically costs attributed to
specialty medications.
What options exist for the Board? (include consequences, impacts, costs, etc. of options):
Without Implementation, the County will continue to pay the higher costs of specialty medications
when copay and discounts are available from the manufacturer.
Recommendation:
Approval as means to reduce specialty pharmacy costs on our health plan.
Approve
Recommendation
Perry L. Buck
Mike Freeman, Pro-Tem
Scott K. James, Chair
Steve Moreno
Lori Saine
O,10 Co
Schedule
Work Session
Other/Comments:
2022-1896
Q2,o033
THE POINT SOLUTIONS MANAGEMENT AMENDMENT
This Amendment, the "Point Solutions Management Amendment", effective October 1, 2022, amends the
Master Services Agreement between Aetna Life Insurance Company, a Connecticut corporation, ("Aetna")
and Weld County Government ("Customer"), dated January 1, 2022 (the "Agreement").
Whereas, Aetna desires to make available the point solutions management services which makes available
to its clients certain third -party digital applications and other products and services ("Point Solutions
Management Services") to Customer; and
Whereas, Customer desires to enroll in the Point Solutions Management Services.
Now, therefore, the parties agree to amend the Agreement as set forth herein.
1. The following provision shall be added to Section 2 (Services) of the Agreement:
"Aetna shall make available to Customer the Point Solutions Management Services in
accordance with the terms and conditions thereof described in Exhibit A, a copy of which
is attached hereto."
2. The terms and conditions of the Agreement remain in effect except as otherwise stated herein. With
respect to the subject matter hereof, this Amendment constitutes the entire agreement between the
parties, superseding all similar terms in any prior understandings, agreements, contracts or
arrangements between the parties, whether oral or written.
3. All capitalized terms used in this Amendment and not otherwise defined shall have the meanings
set forth in the Agreement. If any provision of this Amendment conflicts with any of the provisions
set forth in the Agreement, the provisions of this Amendment shall govern and control.
4. If any provision of this Amendment is held to be void or unenforceable, the remaining provisions
are severable, and their enforceability is not affected or impaired in any way by reason of such law
or holding.
IN WITNESS WHEREOF, the undersigned have duly executed this Amendment as of the date first written
above.
AETNA LIFE INSURANCE COMPANY: CUSTOMER: BOARD OF WELD COUNTY
� � // COMMISSIONERS
By: �4CtitG4AL 11-O.% By:
Its: Strategic Account Executive Its: Mike Freeman, Pro-Tem
Date Signed: 7/6/2022 Date Signed: JUL 0 6 2022
NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY
AND CONSTITUTES TRADE SECRETS OF AETNA.
Proprietary
O2€,e, -/'9-
Exhibit A
Point Solutions Management Service Terms and Conditions
Customer has implemented the Point Solutions Management Service to engage in certain third -party digital
applications and other products and services (each a "PSM Solution" provided by a "PSM Vendor") as set
forth below. PSM Vendors are contracted as subcontractors of Aetna's affiliate, CaremarkPCS Health,
L.L.C. ("CVS Caremark").
1. Customer will enroll in individual PSM Solutions by executing a "Vendor Election
Form" provided by CVS Caremark. Implementation dates of individual PSM Solutions
will be as described in their respective Vendor Election Forms. Aetna shall collect from
Customer and remit to CVS Caremark and CVS Caremark shall remit to PSM Vendors,
the fees described in each Vendor Election Form. Neither Aetna nor CVS Caremark shall
be responsible for funding any portion of the PSM Solutions, but rather shall remit
applicable fees only for amounts properly funded by Customer. The PSM Solution will
be available to employees of Customer residing in the United States, even if they do not
receive other pharmacy benefit services provided or arranged by Aetna through CVS
Caremark.
2. The Point Solutions Management Service processes payments for third -party products
and services. The PSM Solution may include access or use, or otherwise interact with
third party applications, websites and services ("Third Party Applications") to make the
PSM Solution available to Customer. These Third -Party Applications may have their own
terms and conditions of use. Customer understands and agrees that CVS Caremark and
Aetna do not endorse and are not responsible for the terms and conditions of use of those
Third -Party Applications. PSM Solutions and related payments shall not constitute
Claims under the Agreement and are excluded from the calculation of any and all
financial and performance guarantees in the Agreement. Fees for PSM Solutions may not
be paid from any allowances or credits made available to Customer by Aetna under the
Agreement. In the event a PSM Solution impacts the underlying financial terms of the
Agreement, Aetna will review such impact with Customer and may equitably adjust the
same.
3. Communication campaigns, including but not limited to campaigns that raise awareness
of the PSM Solutions, will be designed and executed by PSM Vendors in coordination
with Customer. Data regarding PSM Solutions may be audited pursuant to Customer's
existing audit rights and may take up to ninety (90) days from the date of the data request
if records need to be secured from PSM Vendors. Neither CVS"Caremark nor Aetna will
be liable for any obligations arising from existing agreements with a PSM Vendor, or for
services provided by PSM Vendors other than those provided pursuant to a Vendor
Election Form. Customer is a Covered Entity under the Health Insurance Portability and
Accountability Act of 1996 and its implementing regulations at 45 CFR Parts 160-164
("HIPAA Rules"). To the extent Customer authorizes the disclosure of protected health
information of its members to a PSM Vendor for a PSM Solution, it will comply with
and be subject to the HIPAA Rules.
4. The term of Customer's participation in the Point Solutions Management Service shall
expire one (1) year from the date of execution of this Amendment, and shall thereafter
automatically renew for additional one (1) year terms unless either party provides written
2
NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY
AND CONSTITUTES TRADE SECRETS OF AETNA.
Proprietary
notice of non -renewal at least ninety (90) days before the end of the initial term or any
renewal term; provided that either party may at any time terminate Customer's
participation in the Point Solutions Management Service, or any individual PSM
Solution, upon ninety (90) days' prior written notice to the other party. In the event safety
concerns with a PSM Solution or breach of a PSM Vendor's contract with CVS Caremark
require CVS Caremark to terminate a PSM Solution, CVS Caremark shall notify Aetna
which, in turn, will notify Customer of the termination within five (5) business days.
Upon the termination of Customer's participation in the Point Solutions Management
Service, all Vendor Election Forms will terminate simultaneously with such termination.
3
NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY
AND CONSTITUTES TRADE SECRETS OF AETNA.
Proprietary
cvs
cnReMnIkK
Point Solutions Management
Vendor Election Form (VEF)
PrudentRx
Account Team Information
SAE Name:
Brandon Huck
SAE Phone:
817.291.7468
SAE Email:
Brandon.huckucvshealth.com
AM Name:
Jennifer Ayala
AM Phone:
817.901.3629
AM Email:
Jennifer.avala(ucvshealth.com
Customer Information
Customer Name
("Customer"):
Weld County Government
Eligible Carrier, Account,
& Group(s) (CAG)
7704 / 100661303 / 1090724100001-A, 0109724100002-A
Coalition/TPA/Health
Plan name if different
from Customer name:
Onsite Pharmacy
.1 Yes ❑ No
Customer Type
@ Employer ■ Coalition ❑ TPA ❑ Health Plan
This Vendor Election Form ("VEF"), once executed, is an exhibit to the Point Solutions Management
Amendment ("Amendment") between Aetna Life Insurance Company, ("Aetna"), and Weld County
Government. All capitalized terms used in this VEF and not otherwise defined shall have the meanings set
forth in the Amendment or Agreement. In the event of a conflict between the terms of this VEF and the
terms of this Amendment, the terms of this VEF shall control.
PrudentRx, LLC ("Vendor" or "PrudentRx") provides co -pay program related services to plan sponsors
that include guidance on plan benefit design for specialty products and assistance to members to secure
available copay assistance for specialty drugs through the various programs funded by pharmaceutical
companies ("PrudentRx Solution").
Customer agrees to implement the PrudentRx Solution pursuant to the Point Solutions Management
Amendment effective with the following parameters:
PRUDENTRX SOLUTION:
Additional Defined Terms:
"Benefit Cap" means the maximum amount of funds available from the drug manufacturer under a
Pharma Copayment Assistance Program. The Benefit Cap and copay program periods can vary by drug
manufacturer and the Member's enrollment date in the program. If a Specialty Drug does not have a
Pharma Copayment Assistance Program, the Benefit Cap will be zero for such Specialty Drug for
purposes of the PrudentRx Solution.
"Covered Class" means a therapeutic class that is included in the PrudentRx Solution, as specified on
Attachment 1. Covered Classes are updated from time to time and are available to Customer upon
1
07904\00234\4852-3676-5140.v16
Cvs
cAaenwW
Point Solutions Management
Vendor Election Form (VEF)
PrudentRx
request. Covered Classes may vary depending on Customer's exclusive specialty setup and Program
Drug List selected by Customer.
"Essential Health Benefits" shall have the meaning given to such term at 42 U.S.C. § 18022(b), which
currently includes items and services in the following ten benefit categories: (1) ambulatory patient
services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health
and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7)
rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness
services and chronic disease management; and (10) pediatric services, including oral and vision care.
"Participating Member" means a Member who elects to participate in the PrudentRx Solution whose
prescription drug benefit (1) is administered pursuant to the Agreement and (2) includes the PrudentRx
Solution.
"Pharma Copayment Assistance Program" means a program sponsored by a pharmaceutical
company that provides financial assistance for payment of the patient's cost -share for those patients
who meet the program eligibility criteria, as established by the pharmaceutical company, but excluding
any program that conditions assistance on financial need.
"Program Drug List" means the "PrudentRx Program Drug List," which is a listing of Specialty
Drugs that will be included in the PrudentRx Solution for Customer.
"Program Product" means a Specialty Drug that is listed on the Program Drug List.
"Specialty Tier" means the adjudication tier for Specialty Drugs.
Program Description: The PrudentRx Solution shall consist of the following elements:
• Scope: Pharma Copayment Assistance Programs. The Program is available only to Members.
• Plan Design: For the Plans participating in the PrudentRx Solution, as designated by Customer in
the "Customer Information" in the table above, Customer shall adopt a plan design for Specialty
Drugs in a Covered Class that consists of the following elements:
> Specialty Tier: Customer will implement a Specialty Tier. Products on the Specialty Tier
shall be subject to a thirty percent (30%) Cost Share. All Specialty Drugs in a Covered
Class shall be adjudicated at the Specialty Tier.
➢ Non -Essential Health Benefits: Certain products in a Covered Class shall be deemed non -
Essential Health Benefits.
> Coverage Process: When the Benefit Cap has been reached based on a Pharma Copayment
Assistance Program for a Participating Member for a Program Product and thus the Pharma
Copayment Assistance Program is not available; the Plan shall assume responsibility for
the Cost Share for the Program Product unless and until financial assistance is again
available to the Participating Member under the Pharma Copayment Assistance Program.
This shall include any amounts not paid by a Pharma Copayment Assistance Program, such
as when there is a residual leftover after applying the maximum copay assistance to the
claim.
2
07904\00234\4852-3676-5140.v16
CVS
CARE MAI%
Point Solutions Management PrudentRx
Vendor Election Form (VEF)
➢ Deductible and OOP Max: Amounts paid for the benefit of a Member by a Pharma
Copayment Assistance Program shall not be counted towards the Member deductible or
the Member annual out of pocket maximum obligation.
➢ Summary Plan Description. The Customer shall adopt language in its Summary Plan
Description that aligns with the above requirements. A template for such language is
provided on Attachment 2. Although PrudentRx will assist with the language in the
Summary Plan Description, the Customer and the Plan administrator remain responsible
for fulfilling their fiduciary duties under ERISA with respect to the content of the Summary
Plan Description.
• Program Drug List: Customer shall select a standard Program Drug List, which Program Drug List
shall be subject to review and approval by CVS Caremark to verify plan design alignment with the
Formulary (i.e., no cost share disadvantage of preferred formulary products).
• Member Notification & Enrollment: PrudentRx will work in conjunction with Customer to
develop a communication and enrollment process regarding the PrudentRx Solution, to include the
following:
➢ Enrollment in the PrudentRx program for all eligible Members begins automatically, but
involves a two-step process:
• Step One: Member information is on file with PrudentRx.
Step Two: Member needs to call PrudentRx at 1-800-578-4403 after receipt of the
welcome letter to register for any copay assistance available from drug
manufacturers. Step two of the enrollment process must be completed to be
enrolled
➢ Send a standardized and non -editable notice to Members utilizing a Specialty Drug in a
Covered Class identified via historic claim files approximately thirty-five (35) days prior
to intended implementation date of the PrudentRx Solution. Approximately five (5) to
seven (7) business days after notice has mailed, PrudentRx will coordinate telephonic
outreach to Members who have yet to contact PrudentRx to complete step two of the
enrollment process.
➢ Implement the PrudentRx high touch comprehensive communication process for Members
who are projected to participate in the PrudentRx Solution at the customers launch date.
Once the PrudentRx Solution is live for Customer, PrudentRx will identify net -new utilizers within
one (1) business day of receipt of a claim for a Specialty Drug in a Covered Class. PrudentRx shall
conduct outreach to the Member if the Member is not currently enrolled in an available Pharma
Copayment Assistance Program. PrudentRx shall coordinate with the Member and seek to
complete Member enrollment in the applicable Pharma Copayment Assistance Program within
three (3) business days of receipt of such claim, subject to Member satisfaction of the eligibility
requirements of such Pharma Copayment Assistance Program.
Initials of Customer's Authorized Representative
3
07904\00234\4852-3676-5140.v16
yi\e
07-0Z1 /19
cvs
cnReMnqN
Point Solutions Management
Vendor Election Form (VEF)
PrudentRx
• Pharma Copayment Assistance Program Enrollment: PrudentRx shall assist Participating Members
with enrollment in Pharma Copayment Assistance Programs for Specialty Drugs and securing
financial assistance under such Pharma Copayment Assistance Programs.
• Coordination with CVS Caremark. PrudentRx collaboratively works with CVS Caremark and, if
requested by CVS Caremark, the dispensing pharmacies, to ensure timely prescription processing
with minimal member abrasion by providing real time data feeds, to include notification to CVS
Caremark of: (i) decision by a Member to not participate in the PrudentRx Solution; (ii) inability
to contact a Member; (ii) election by a Member to participate in the PrudentRx Solution; and (iv)
enrollment of a Participating Member in a Pharma Copayment Assistance Program.
Customer hereby directs and authorizes CVS Caremark to: (i) exclude amounts paid under Pharma
Copayment Assistance Programs from Member deductible and annual Member out of pocket
maximum obligation; (ii) provide to PrudentRx daily paid claims, daily reject files, and monthly
claims files for Program Products dispensed to Participating Members so that PrudentRx may
implement and operate the PrudentRx Solution (collectively, "Customer Data"); and (iii) provide
PrudentRx with Member portal (Customer Online Services) access for designated PrudentRx
employees performing Participating Member benefit verification and eligibility in real time, if
possible.
• Confidentiality. In the event Customer receives any Confidential Information (as such term is
defined in the Agreement) of PrudentRx, Customer shall maintain the confidentiality of such
Confidential Information consistent with the requirements imposed in the Agreement for
confidential treatment of CVS Caremark Confidential Information.
• Release of Data. Customer hereby authorizes and directs CVS Caremark to disclose the Customer
Data and other Customer or Member information to PrudentRx in order to provide the PrudentRx
Solution to Customer. Customer acknowledges and agrees that to the extent any data disclosed to
PrudentRx includes Member information, such Member information shall be disclosed by Aetna
subject to the Business Associate Agreement between Customer and Aetna.
• Claims Audits. On a monthly basis, Prudent Rx shall: (i) retroactively audit claims for the prior
month to ensure the PrudentRx Solution was implemented appropriately for each Participating
Member for whom a claim was adjudicated in such month, including implementation of the
coverage process whereby the Plan assumes responsibility for the Cost Share; and (ii) provide a
written report with the results of such audit to CVS Caremark and Customer within thirty (30) days
of the end of the month subject to the audit. If any issues are identified, PrudentRx shall consult
with CVS Caremark to coordinate on an appropriate resolution.
• Control of Plans. Customer acknowledges and agrees that PrudentRx shall not be: (i) the
administrator (as that term is defined in Section 3(16) of ERISA) of any Plan for any purpose; (ii)
a named fiduciary with respect to any Plan for purposes of ERISA or any applicable state law; (iii)
delegated discretionary authority or responsibility, or exercise discretionary authority or control,
with respect to any Plan or its administration; or (iv) deemed to be a fiduciary with respect to any
Plan for purposes of ERISA or any applicable state law.
• HDHP. Customer acknowledges that the PrudentRx Solution is not recommended for high -
deductible health plans ("HDIIP") with health savings accounts ("IBA"). Customer is solely
responsible for evaluating compliance with the Internal Revenue Code and IRS guidance, in
4
07904\00234\4852-3676-5140.v16
cvs
cAaemnIkc
Point Solutions Management
Vendor Election Form (VEF)
PrudentRx
consultation with its own counsel, in connection with any contemplated implementation of the
PrudentRx Solution for any HDHPs or HSAs and Customer is solely responsible for any loss, cost,
damage or expense resulting from any such implementation.
• Reporting. PrudentRx shall provide the following reports to Customer:
➢ On a monthly basis, PrudentRx will provide a summary to Customer of the claims it
processed with respect to the Plan, which shall include the following metrics:
• PrudentRx Generated Savings
• Total Specialty Drug spend subject to PrudentRx Solution
• Total net savings after Service Fee
• Summary YTD by Covered Class
• Including the number of Members and number of claims under each
Covered Class
All information disclosed on the foregoing reports shall comply with the privacy requirements
under HIPAA and any other applicable law.
• Invoicing: PrudentRx shall provide monthly claims detail and the Service Fee to CVS Caremark.
CVS Caremark will invoice Customer the Service Fee on the monthly administrative service fees
invoice.
• Early Termination: CVS Caremark may immediately terminate this VEF in the event CVS
Caremark determines, in its reasonable discretion, that such termination is necessary to avoid or
limit an adverse financial impact on CVS Caremark and/or Customer.
PrudentRx Solution Effective Date: 10/1/2022
Note: The PrudentRx Solution Effective Date must be the first day of the month, cannot be sooner than the
effective date of the Point Solutions Management Amendment, and cannot be sooner than 90 calendar days
from the date of delivery of an executed copy of this Vendor Election Form to
PointSolutionsManagement@CVSHealth.com. In the event this Vendor Election Form is not delivered
at least 90 calendar days prior to the proposed PrudentRx Solution Effective Date or otherwise fails to
meet the timing requirements of the prior sentence, this Vendor Election Form shall not take effect and
the Customer shall be requested to submit a new Vendor Election Form with a conforming PrudentRx
Solution Effective Date.
Eligible Member Population:
. Customer's PBM-covered employees
Dependents of Customer's employees
D../
Compensation: Customer will pay a service fee equal to twenty-five percent (25%) of Generated Savings
(the "Service Fee").
• "Generated Savings" are calculated as the amount by which the Current Plan Net Cost exceeds the
New Plan Net Cost.
• "Current Plan Net Cost" is (i) the Plan's gross cost of a Specialty Drug, less (ii) the amount obtained
by multiplying the Current Copayment Percentage by the gross cost of the Specialty Drug (without
the application of any deductibles).
5
07904\00234\4852-3676-5140.v16
cvs
CARE MIWIC
Point Solutions Management PrudentRx
Vendor Election Form (VEF)
• "New Plan Net Cost" is (i) the Plan's gross cost of the Specialty Drug, less (ii) the amount of
manufacturer copay assistance applied to the gross cost of the Specialty Drug.
• "Current Copayment Percentage" is the lesser of: (i) six percent (6%) or (ii) the percentage obtained
by dividing the total copayments paid by Members for Specialty Drugs (without the application of
any deductible) by the total gross cost of the Specialty Drugs for the Plan, each measured over the
twelve (12) month period immediately preceding the implementation of the PrudentRx Solution. If
historical claims data is not provided to PrudentRx to determine this amount, the Current Copayment
Percentage will be deemed to be 2%.
PrudentRx may share a portion of the above service fee to third parties, including CVS Caremark, for services
rendered in connection the PrudentRx Solution. There are no separate fees for administration, Member
outreach and support, monthly reporting, or any of the other services provided by PrudentRx under the
PrudentRx Solution.
Examples of the calculations of the PrudentRx Generated Savings and the service fee are illustrated below:
Examples Of The Calculations Of The Prudentrx Generated Savings And The Service Fee Are Illustrated Below:
t no*.
\ nettle
t
t tan** 4
t septa S
f .aniFie
I sample/
t amnia, s
IIUW Pt; f.•t'tes 1..•I'rt ea i0. \.1Y.'.:-% /11.• ( rl• IIIYII��
cal,Hy a-.W1t Ill,
I I:11,y 1 Liu 1•
Platt • l,r•r 1 .).1
`:1.Ir t•
.. 1.. pal . SaJ.1..! t.t
J.II h.."r 1 ..• ti•.
t•..• I •..1
\tu an'
I .,1.404 11 y..•.1.,•:.
1'ul,..rt.Ir,;•.
trite I In, 1 •.•.t
\hart
,.,1.'y A-.s.".i.1'..•
CtV1, A Vet tArt( .• 1x.11 f al)/ 1..•..I♦
P%.t A.ntat•4 Meth al. t •.t
11%.IIL(
1 .1•,.1 .. I �1 •.r.
lyl ♦•.•• 14, .1 ��..
t.
Total Amount Pahl by all Source (Taal Gross Cost)
Initial Plan Cost
Manutaclurer 9M Amount (Co•Insurance)
Manufacturer Copay Assistance Pay Amount
Cod Amount'
Manutactwer Copay Assistlnct Paid Amount
lase Roe member sayArr (Current Copayment Percentage)"'
PrudentR,c Generated Savings
Pruden*A.0 fN
NM Plan Savings
56.000.00
54,200.00
61,000.00
S1200.00
50.00
51,000.00
$120.00
51.600.00
5.420.00
$1,260.00
56,000.0
Sit MOO
51.1100.00
51,000.00
5000
51,000.00
$12000
5000.00
$220.00
566000
SCOW W
54.200.00
51.000.00
$1,790.00
$10
51.790.00
512040
S1.670.00
5417.50
$1,?S2 SO
$0.0/0.0
54.200.00
51,800.00
So
$1,000
$0.00
$120.00
(5120.00)
(5110.00►
$0.00
$6.000•oo
54.200.00
51200.00
Sso
S1ari0
$50.00
5120.00
(570.00)
($70.00)
$0000
56.000.00
56.000-00
So.00
So
SO
50.00
$1000
Ono Doi
($10.00)
510.00
$'0&00
55.000.00
$1.000.00
S0
51.000
WOO
5120.00
(5120.00)
($120.00)
50.00
Stoma)
Ss oto0
Ss.aeo
51.0000
SO
S1.000.00
5120.00
$000.00
$220.00
$660.00
*This shall include any amounts not paid by manufacturer copay assistance program, such as when there is a
residual left over after applying the maximum copay assistance to the claim or when copay assistance is not
available.
* * Maximum -Out -Of -Pocket may vary by plan. The example above is set at $1,000 for illustration purposes
* * * Baseline member savings (Current Copay Percentage) is set at 2% for illustration purposes. Example 4
above illustrates negative amounts for the PrudentRx Generated Savings and the program fee. To the extent
a claim results in negative amounts as in this Example 4 (which such negative amounts are not generally
intended by this program), the negative program fee amount will be netted against other positive program fee
amounts occurring in the same reporting period, thereby reducing the total program fee amount (but not below
$0) payable to PrudentRx. If, for any month, the aggregate program fee is negative, the amount will be carried
forward and applied as a credit against the next month's invoice.
6
07904\00234\4852-3676-5140. v16
CVS
Point Solutions Management
Vendor Election Form (VEF)
PrudentRx
ac
Signature of Customer's Authorized Signature of Aetna's Strategic Account Executive
Representative
Name (Print): Mike Freeman
Pro—Tem, Board of Weld
Title: County Commissioners
Date Signed: JUL 0 6 2022
(MM/DD/YYYY)
7
07904\00234\4852-3676-5140.v 16
Date Signed:7/6/2022
(MM/DD/YYYY)
01vo?o% -/i94
cvs
cnaEMnRIc
Point Solutions Management
Vendor Election Form (VEF)
PrudentRx
Attachment 1
Covered Classes
ACROMEGALY
ALPHA -1 ANTITRYPSIN DEFICIENCY
AMYLOIDOSIS
ANEMIA
ASTHMA
ATOPIC DERMATITIS
AUTOIMMUNE
COAGULATION DISORDERS
CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES
CYSTIC FIBROSIS
ELECTROLYTE DISORDERS
GASTROINTESTINAL DISORDERS -OTHER
GOUT
GROWTH HORMONE AND RELATED DISORDERS
HEMATOPOIETICS
HEMOPHILIA
HEPATITIS B"
HEPATITIS C
HEREDITARY ANGIOEDEMA
HORMONAL THERAPIES
HUMAN IMMUNODEFICIENCY VIRUS'
IMMUNE DEFICIENCIES AND RELATED DISORDERS
INFECTIOUS DISEASE - OTHER
INFERTILITY..
INFLAMMATORY BOWEL DISEASE
IRON OVERLOAD
LYSOSOMAL STORAGE DISORDER
MENTAL HEALTH CONDITIONS
MOVEMENT DISORDERS
MULTIPLE SCLEROSIS
NEUTROPENIA
OCULAR DISORDERS*
ONCOLOGY
OSTEOPOROSIS
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA
PHENYLKETONURIA
PRE -TERM BIRTH
PULMONARY ARTERIAL HYPERTENSION
PULMONARY DISORDERS - OTHER
8
07904\00234\4852-3676-5140.v16
Cvs
CAREMAIC
Point Solutions Management
Vendor Election Form (VEF)
PrudentRx
RARE DISORDERS - OTHER
RENAL DISEASE
RESPIRATORY SYNCYTIAL VIRUS
SEIZURE DISORDERS
SICKLE CELL DISEASE
SLEEP DISORDER
SYSTEMIC LUPUS ERYTHEMATOSUS
THROMBOCYTOPENIA
TRANSPLANT"
UREA CYCLE DISORDERS
• ONLY AVAILABLE IF CUSTOMER HAS ENHANCED EXCLUSIVE SPECIALTY
NOT AVAILABLE IF THE PARTICIPATING CUSTOMER HAS A FERTILITY MAB
9
07904\00234\4852-3676-5140.v16
CVS
Point Solutions Management
Vendor Election Form (VEF)
PrudentRx
Attachment 2
Summary Plan Description
Disclaimer: The following summary plan description language is a suggested template, and neither CVS Caremark
nor PrudentRx take responsibility for the summary plan description that is published by the Plan. Final language
should be tailored to client plan design and reviewed by customer legal counsel.
PrudentRx Solution for Specialty Medications
In order to provide a comprehensive and cost-effective prescription drug program for you and your family, [Insert
Plan name] has contracted to offer the PrudentRx Solution for certain specialty medications. The PrudentRx Solution
assists members by helping them enroll in manufacturer copay assistance programs. Medications on the Plan's
specialty drug list are included in the program and will be subject to a 30% co-insurance. However, if a member
enrolls in an available manufacturer copay assistance program for their specialty medication, the member will have a
$0 out-of-pocket responsibility for their prescriptions covered under the PrudentRx Solution.
Copay assistance is a process in which drug manufacturers provide fmancial support to patients by covering all or
most of the patient cost share for select medications - in particular, specialty medications. The PrudentRx Solution
will assist members in obtaining copay assistance from drug manufacturers to reduce a member's cost share for eligible
medications thereby reducing out-of-pocket expenses. Participation in the program requires certain data to be shared
with the administrators of these copay assistance programs, but please be assured that this is done in compliance with
1- IPAA.
If you currently take one or more specialty medications included in the PrudentRx Program Drug List, you will receive
a welcome letter and phone call from PrudentRx that provides specific information about the program as it pertains to
your medication. All eligible members must call PrudentRx at 1-800-578-4403 to register for any manufacturer copay
assistance program available for your specialty medication as some manufacturers require you to sign up to take
advantage of the copay assistance that they provide for their medications. If you choose to opt out of the program, you
must call 1-800-578-4403. PrudentRx will also contact you if you are required to enroll in the copay assistance for
any medication that you take. Eligible members who choose to decline enrollment in an available manufacturer copay
assistance program will be responsible for the full amount of the 30% co-insurance on specialty medications that are
eligible for the PrudentRx Solution.
If you or a covered family member are not currently taking, but will start a new medication covered under the
PrudentRx Solution, you can reach out to PrudentRx or they will proactively contact you so that you can take full
advantage of the PrudentRx Solution. PrudentRx can be reached at 1-800-578-4403 to address any questions regarding
the PrudentRx Solution.
The PrudentRx Program Drug List may be updated periodically by the Plan.
Copayments for these medications, whether made by you, your plan, or a manufacturer's copay assistance program,
will not count toward your plan deductible.
Because certain specialty medications do not qualify as "essential health benefits" under the Affordable Care Act,
member cost share payments for these medications, whether made by you or a manufacturer copayment assistance
program, do not count towards the Plan's out-of-pocket maximum. A list of specialty medications that are not
considered to be "essential health benefits" is available. An exception process is available for determining whether a
medication that is not an essential health benefit is medically necessary for a particular individual.
PrudentRx can be reached at 1-800-578-4403 to address any questions regarding the PrudentRx Solution.
07904\00234\4852-3676-5140.v16
APPROVED AS TO SUBSTANCE:
/fflected• Offici"epartment Head
tie
APPROVED AS T • FUNDING:
Chief Financial Officer / Controller
AP.' ;/ VED AST ,,ORM:
77191
County Attorney
Hello