Script Care, Ltd - RP Riley Management Group Inc.



Script Care, Ltd.

6380 Folsom Dr.

Beaumont, TX 77706

(800) 880-9902

Contact Info:

Primary Contact:

|Name: |Gary Robards |

|Company Name: |RP Riley Management Group |

|Physical & Mailing Address: |822Andover Drive |

|City, State Zip: |Eagle, WI 53119 |

|Phone: |262-363-2700 ext 222 |Fax: |262-363-5556 |

|E-mail: |grobards@ |

Billing Contact:

|Name: |Claire Stella |

|Company Name: |RP Riley Management Group |

|Physical & Mailing Address: |822 Andover Drive |

|City, State Zip: |Eagle, WI 53119 |

|Phone: |262-363-2700 ext 221 |Fax: |262-363-5556 |

|E-mail: |cstella@ |

|Tax ID Number: |35-2424666 |

|Billing: | Electronic Flat File (requires SFTP/FTP) X Electronic PDF Document |

|Additional Invoice Email Notifications | |

Eligibility Contact:

|Name |Claire Stella |

|Company Name: |RP Riley Management Group |

|Physical & Mailing Address: |822 Andover Drive |

|City, State Zip: |Eagle, WI 53119 |

|Phone: |262-363-2700 ext 221 |Fax: |262-363-5556 |

|E-mail: |cstella@ |

Client Name and Contact (Required):

|Name | |

|Company Name: | |

|Physical & Mailing Address: | |

|City, State Zip: | |

|Phone: | |Fax: | |

|E-mail: | |

|Tax ID Number: | |

Broker Name and Contact:

|Name | |

|Company Name: | |

|Physical & Mailing Address: | |

|City, State Zip: | |

|Phone: | |Fax: | |

|E-mail: | |

GROUP INFORMATION:

|Group Name: | |

|Group Number: | |

|Effective Date: | |

|Business/Corporate Sector: | |

Identification Cards:

Customized Plastic Cards – Rx & Medical (Combo Card) X Standard Plastic Cards – Rx Only Card

No Cards – Cards are being printed by Group, TPA, etc.

Eligibility Information:

|Enrollment Count: |# of Employees (required): | | |Total # of Dependents: | |

Dependent Information Provided on Census? Yes No

Use Location or Division Codes: Yes (must be submitted on census) No

| Electronic File Submission (requires SFTP/FTP) |File Frequency | |

|Files will be submitted by: | Plan Sponsor | Other | |

CMS Medicare Part D RDS Program:

Is the group currently participating in the CMS Medicare Part D RDS Program? Yes No

|Number of Covered Retirees (65+): | | |Dependents (65+): | |

N/A - Group does not cover Retirees

Direct Member Reimbursement:

X Not Allowed Reimburse at contract price less co-payment. Reimburse at amount billed less co-payment.

|How many days? | |after which the Rx will be processed at contract price less copay. |

| | |Maximum number of days to allow submission for member reimbursement |

Dispense as Written Override:

Yes Allows patient to override generic substitution allowed by doctor and NOT BE PENALIZED. Patient will pay only the present co-payment.

X No Does not allow patient to override generic substitution allowed by doctor. Patient must pay difference in price between the BRAND NAME drug and the GENERIC drug plus the brand name co-payment. This price difference does not apply toward deductible.

DAW Penalty: Applicable or Not Applicable to $0 copay drugs (no cost-sharing drugs)

Disease Management:

None Tier 1 Identification Only Tier 2 Identification and Disease Mgmt

Online Reports:

|Spec Amount: | $500 | $1000 | Other: |$ |

Reports:

| Standard Report Package | Cycle | Monthly | Quarterly |

INTEGRATED HDHP/HSA PLANS (RX & MEDICAL): (Requires SFTP/FTP)

HDHP HSA N/A

Deductible:

Per calendar year Per contract year N/A

|Per Member: |$ |And/or Per Family: |$ |

Apply to: Retail Mail Order Specialty All

Applicable or Not Applicable to Brand only drugs (generics n/a to deductible)

Is the Deductible included in the Maximum Out of Pocket, if applicable? Yes No

Maximum Out of Pocket:

Per calendar year Per contract year N/A

|Per Member |$ |And/or Per Family |$ |

Apply to: Retail Mail Order Specialty All

Applicable or Not Applicable to Brand only drugs (generics n/a to OOP)

Maximum Benefit:

Per calendar year Per contract year N/A

|Per Member: |$ |And/or Per Family |$ |

Apply to: Retail Mail Order Specialty All

Applicable or Not Applicable to $0 copay drugs (no cost-sharing drugs)

Max Dollar Per Script:

|SCL Internal Max $4,999.97 | Other: |$ |

Plan Authorization is required for scripts exceeding $9,999.97. Requests will be submitted to designated contact for review/approval.

Letter of Medical Necessity is required for scripts exceeding $9,999.97. Requests will be submitted to designated contact for review/approval.

SFTP/FTP:

| Secure SFTP Standard FTP with PGP/GPG (key required) | N/A |

|External IP Address(s) | |

Retail Copays:

|Option |Brand with Generic | | | |

| | | | |Default Dispensing Limits: |

| | | | | |

| | | | |Retail: 30 day supply |

| | | | | |

| | | | |Plans without Mail Order: |

| | | | |Acute Care Drugs: 34 day supply |

| | | | |Maintenance Drugs: 90 day supply * |

| | | | |* Charge 1 copay per 30 days |

|A |Brand w/o Generic | | | |

| |Generic | | | |

| | | |

|Option |Non-Preferred Brand (Non-Formulary) | | | |

|B |Preferred Brand (Formulary) | | | |

| |Generic | | | |

| | | |

|Other: | | |

Retail 90 Day Network:

|Option |Brand with Generic | | | |

| | | | |Retail 90 Day Network Default Setup: |

| | | | | |

| | | | |1 copay per 30 days |

| | | | | |

| | | | |Other |

|A |Brand w/o Generic | | | |

| |Generic | | | |

| | | |

|Option |Non-Preferred Brand (Non-Formulary) | | | |

|B |Preferred Brand (Formulary) | | | |

| |Generic | | | |

| | | |

|Other: | | |

Mail Order Copays:

|Option |Brand w/ Generic | | |Mail Order: 90 day supply |

| | | | | |

|A |Brand w/o Generic | | | |

| |Generic | | | |

| | | |

|Option |Non-Preferred Brand (Non-Formulary) | | | |

|B |Preferred Brand (Formulary) | | | |

| |Generic | | | |

|Other: | | |

SCL Specialty Pharmacy Copays:

| | | None | Mandatory After |

| | |Non-Mandatory |1st Fill at Retail |

| | |Mandatory |2nd Fill at Retail |

| | | |Other ___________ |

|Option |Bra| |

|A |nd | |

| |w/ | |

| |Gen| |

| |eri| |

| |c | |

|Option |Non-Preferred (Non-Formulary) | | |Default Setup: 30 day supply |

|B | | | |Other |

| | | | |Specialty copays apply to specialty eligible drugs at |

| | | | |retail |

| |Preferred (Formulary) | | | |

| |Generic | | | |

|Note: Specialty Pharmacy requires injectables to be covered. |

SCL Diabetic Program Copays:

| |Dia|Diabetic Supplies | |

| |bet| | |

| |ic | | |

| |Dru| | |

| |gs | | |

|Option |

|B |

SCL Compound Program Copays:

|Option |Brand w/ Generic | | |Mandatory for Compounds over $100 |

|A |Brand w/o Generic | | | Max $ Other |

| |Generic | | | Copay same as Retail |

| | | |

|Option |Non-Preferred Brand (Non-Formulary) | | | |

|B |Preferred Brand (Formulary) | | | |

| |Generic | | | |

Member addresses are required in Pharmscreens if participating in the SCL Specialty, Diabetic or Compound Programs.

Drug Coverage:

|Drug Category |Examples |SCL Recommended Coverage |Benefit Coverage Changes |Custom Limitations |

| | |Use Standard SCL Plan |Change Recommended Coverage | |

|All Injectables – will follow coverage unless |Enbrel, Lovenox, | Include | Include PA LMN Exclude | |

|specific medication detailed in other sections|Testosterone Cypionate | | | |

|Anaphylaxis Therapy Agents (Injectables) |Epipen | Include | Include PA LMN Exclude | |

|Compounds |Products mixed by a Pharmacist | Include with $100 Maximum | Include PA LMN Exclude |Max $ |

|Contraceptives | | | | |

|(See next page for ACA Covg) | | | | |

|Cosmetic Agents: | | | | |

|1. Hair Loss |1. Rogaine, Propecia |1. Exclude |1. Include PA LMN Exclude |1. |

|2. Wrinkles |2. Botox Cosmetic, Retin-A, Renova |2. Include if age less than 26 years |2. Include PA LMN Exclude |2. |

| | |Exclude if age greater than 25 years | | |

|Dermatology (Acne/Skin Disease) |Differin, Claravis | Include | Include PA LMN Exclude | |

|Diabetic Supplies: | | | | |

|1. Insulin |1. Self Explanatory |1. Include |1. Include PA LMN Exclude |1. |

|2. Syringes & Needles |2. B-D syringes |2. Include |2. Include PA LMN Exclude |2. |

|3. Alcohol Swabs |3. Self Explanatory |3. Include |3. Include PA LMN Exclude |3. |

|4. Insulin Injection Devices |4. Novopen |4. Include |4. Include PA LMN Exclude |4. |

|5. Lancets |5. Self Explanatory |5. Include |5. Include PA LMN Exclude |5. |

|6. Lancet Devices |6. Soft Touch, Monojector |6. Include |6. Include PA LMN Exclude |6. |

|7. Test Strips (Blood & Urine) |7. Self Explanatory |7. Include |7. Include PA LMN Exclude |7. |

|8. Glucose Monitors |8. Accu-Chek |8. Exclude |8. Include PA LMN Exclude |8. |

|Anti-Diabetic Injectables |Byetta, Symlin, Glucagon | Include | Include PA LMN Exclude | |

|Diagnostic Agents |HIV tests, Pregnancy test | Exclude | Include PA LMN Exclude | |

|Dietary Products |Ensure, Metanx, Foltx | Exclude | Include PA LMN Exclude | |

|Erectile Dysfunction: | | | | |

|1. Oral |1. Viagra |1. Exclude |1. Include PA LMN Exclude |1. / day supply |

|2. Injectable |2. Caverject, Edex |2. Exclude |2. Include PA LMN Exclude |2. / day supply |

|Fertility Agents: | | | | |

|1. Injectable |1. Gonal-F, Fertinex |1. Exclude |1. Include PA LMN Exclude |1. |

|2. Oral |2. Clomid |2. Exclude |2. Include PA LMN Exclude |2. |

|Growth Hormones |Genotropin, Humatrope | Exclude | Include PA LMN Exclude | |

|Immunological Vaccines |Allergy shot | Exclude | Include PA LMN Exclude | |

|(See next page for ACA coverage) | | | | |

|Medical Devices & Supplies |Respiratory, Ostomy, Dialysis | Exclude | Include PA LMN Exclude | |

|Non-Insulin Syringes/Needles |Self Explanatory | Exclude | Include PA LMN Exclude | |

|Over the Counter (OTC) | Prilosec OTC, Nexium OTC | Exclude | Include PA LMN Exclude | |

|(See next page for ACA Covg) | | | | |

|Vitamins: (See next page for ACA Covg) | | | | |

|1. Rx Vitamins |1. Self Explanatory |1. Exclude |1. Include PA LMN Exclude |1. |

|2. Rx Prenatal |2. Self Explanatory |2. Include |2. Include PA LMN Exclude |2. |

|3. Injectable |3. Thiamine HCL |3. Include |3. Include PA LMN Exclude |3. |

|Weight Loss Drugs: | | | | |

|1. ADHD Drugs |1. Ritalin, Adderall |1. Include |1. Include PA LMN Exclude |1. Age Limit: |

|2. Anorexiants |2. Xenical, Meridia |2. Exclude |2. Include PA LMN Exclude |2. |

ACA Exemptions

N/A Religious (Contraceptives will be excluded) Grandfathered (ACA $0 copay does not apply. Benefit Coverage Must be selected below.)*

ACA PREVENTIVE MEDICATION DRUG COVERAGE, no cost-share (copay, coinsurance or deductible) $0

|Drug Category |Applies to |*Benefit Coverage for ACA Exempt Plans |*Custom Limitations for ACA Exempt Plans |

|Preventive Medications: | | | |

|1. Aspirin, Generic OTC*, no greater than 325mg |Men ages 45-79 and Women ages 55-79 |1. Include PA LMN Exclude |1. |

|2. Folic Acid, Generic OTC*, 0.4 and 0.8mg |Women up to age 50 |2. Include PA LMN Exclude |2. |

|3. Iron Supplements, Generic OTC* and RX |Children ages 6 -12 months |3. Include PA LMN Exclude |3. |

|4. Vitamins w/Fluoride, Generic OTC* and Rx |Children ages 6 months – 5yrs |4. Include PA LMN Exclude |4. |

|5. Vitamin D, Generic OTC* and Rx, all strains |Women ages 65 and over |5. Include PA LMN Exclude |5. |

|Immunological Vaccines: | | | |

|1. Tetanus |1. Self Explanatory | Include PA LMN Exclude |1. |

|2. Diptheria |2. Self Explanatory | Include PA LMN Exclude |2. |

|3. Pertussis (Td/Tdap) |3. Self Explanatory | Include PA LMN Exclude |3. |

|4. Human papillomavirus (HPV) |4. Self Explanatory | Include PA LMN Exclude |4. |

|5. Varicella |5. Self Explanatory | Include PA LMN Exclude |5. |

|6. Zoster |6. Self Explanatory | Include PA LMN Exclude |6. |

|7. Measles |7. Self Explanatory | Include PA LMN Exclude |7. |

|8. Mumps |8. Self Explanatory | Include PA LMN Exclude |8. |

|9. Rubella (MMR |9. Self Explanatory | Include PA LMN Exclude |9. |

|10. Influenza |10. Self Explanatory | Include PA LMN Exclude |10. |

|11. Pneumococcal (polysaccharide) |11. Self Explanatory | Include PA LMN Exclude |11. |

|12. Hepatitis A |12. Self Explanatory | Include PA LMN Exclude |12. |

|13. Hepatitis B |13. Self Explanatory | Include PA LMN Exclude |13. |

|14. Meningococcal |14. Self Explanatory | Include PA LMN Exclude |14. |

|Contraceptives: | | | |

|1. Devices |1. Mirena IUD, Diaphragm | Include PA LMN Exclude |1. |

|2. Implant |2 Implanon, Nexplanon | Include PA LMN Exclude |2. |

|3. Injectable |3. Depo-Provera | Include PA LMN Exclude |3. |

|4. Oral |4. Ortho Tri-Cyclen, Yasmin | Include PA LMN Exclude |4. |

|5. Extended-Cycle Oral |5. Seasonale, Seasonique | Include PA LMN Exclude |5. |

|6. Transdermal |6. Ortho Evra | Include PA LMN Exclude |6. |

|7. Vaginal |7. Nuvaring | Include PA LMN Exclude |7. |

|8. Emergency |8. Plan B | Include PA LMN Exclude |8. |

|9. OTC* |9. Spermicides, Sponges, Condoms | Include PA LMN Exclude |9. |

|Smoking Cessation Products (Rx) |Limitations | | |

|Chantix (starter pack) |2 per year | Include PA LMN Exclude |1. |

|Chantix |224 tablets per year | Include PA LMN Exclude |2. |

|Bupropion |360 tablets per year | Include PA LMN Exclude |3. |

|Nicotrol Inhaler |2688 cartridges per year | Include PA LMN Exclude |4. |

|Nicotrol Nasal Spray |90 bottles per year | Include PA LMN Exclude |5. |

|Nicoderm Patch |140 patches per year | Include PA LMN Exclude |6. |

|Nicoderm Gum |480 pieces per year | Include PA LMN Exclude |7. |

|Nicoderm Lozenge |480 pieces per year | Include PA LMN Exclude |8. |

*Requires a prescription from a physician and must be purchased at a pharmacy to obtain the zero-cost share.

Drug Limitations:

|Drug Category |Recommended Limitations |SCL Recommended Coverage |Benefit Coverage |Custom Limitations |

| |Use Recommended Limitations unless |Use Standard SCL Plan | | |

| |specified otherwise | | | |

|1. Amerge |1. 9 tabs/30 days |1. Include |1. Include PA LMN Exclude |1. |

|2. Axert |2. 12 tabs/30 days |2. Include |2. Include PA LMN Exclude |2. |

|3. Copegus |3. 168 tabs/28 days |3. Include |3. Include PA LMN Exclude |3. |

|4. Fentanyl Lozenge |4. 120 units/30 days |4. Exclude |4. Include PA LMN Exclude |4. |

|5. Frova |5. 9 tabs/30 day |5. Include |5. Include PA LMN Exclude |5. |

|6. Imitrex/Sumavel Injection |6. 4 Stat Dose Systems or 4 Stat Doses or |6. Include |6. Include PA LMN Exclude |6. |

| |4 vials | | | |

|7. Imitrex Nasal Spray |7. 1 box/30 days |7. Include |7. Include PA LMN Exclude |7. |

|8. Imitrex Tablets |8. 18 tabs/30 days (all strengths) |8. Include |8. Include PA LMN Exclude |8. |

|9. Maxalt, Maxalt MLT |9. 18 tabs/30 days |9. Include |9. Include PA LMN Exclude |9. |

|10. Migranal Nasal Spray |10. 1 box/30 days |10. Include |10. Include PA LMN Exclude |10. |

|11. OxyContin/Oxycodone (all strengths) |11. Lesser of 30 days or 100 units |11. Exclude |11. Include PA LMN Exclude |11. |

|12. Relpax |12. 6 tabs/30 days |12. Include |12. Include PA LMN Exclude |12. |

|13. Stadol Nasal Spray |13. 2 bottles/30 days |13. Include |13. Include PA LMN Exclude |13. |

|14. Zomig, Zomig ZMT |14. 6 tabs/30 days |14. Include |14. Include PA LMN Exclude |14. |

|15. Zomig Nasal Spray |15. 1 box/30 days |15. Include |15. Include PA LMN Exclude |15. |

|16. Xyrem | |16. Include |16. Include PA LMN Exclude |16. |

Definitions:

Acute Care Drug – Drug that treats short-term illness or injury

Maintenance Drug – Drug that most common use is to treat a chronic disease state when a therapeutic endpoint cannot be determined

Mandatory – Limit to only one pharmacy provider for the program

Non-mandatory – Allow all network pharmacies as providers for the program

Major Medical – File prescriptions through the medical benefit

Opt-out – The member has the opportunity to choose not to participate in the program

Additional Plan Design Notes:

PA/LMN CONTACT INFO:

|Prior Authorization Contact | |Letter of Medical Necessity Contact |

|Contact Name: | | |Contact Name: | |

|Company Name: | | |Company Name: | |

|Phone: | |Fax: | | |Phone: | |Fax: | |

|E-mail: | | |E-mail: | |

Member addresses are required in PharmScreens if PA’s and/or LMN’s are required for drug coverage.

Payment Procedures for Script Care, Ltd. Prescription Drug Programs:

Script Care, Ltd. (SCL) operates as a “Pharmacy Benefit Manager” and provides pharmaceutical services to plan sponsors through a national pharmacy network. SCL invoices plan sponsors for prescription drug charges twice a month for charges incurred from the 1st through the 14th and from the 15th through the end of the month. Payment for each invoice is due by the due date stated on the invoice, which coincides with the close of the next billing cycle. Charges incurred from the 1st of the month through the 14th are due by the end of the month, and charges incurred from the 15th of the month through the end of the month are due by the 14th of the following month. This procedure is required to comply with prompt payment procedures contained in provider agreements through network pharmacies.

The following procedures will apply and will be included in the Script Care, Ltd., Agreement:

• If payment for any billing cycle is not received by the due date appearing on the invoice, the invoice will be deemed past due. Prescription transactions must be suspended by Script Care, Ltd. without advance notice at anytime an invoice is past due.

• The plan may be reinstated if payment of all past due amounts is received by Script Care, Ltd. within ten (10) working days of this action.

• Thereafter, a written request to reinstate and full payment of any amounts due must be received by Script Care, Ltd. before reinstatement will occur. Script Care, Ltd. as a normal business practice does not require security deposits from plan sponsors. However, Script Care, Ltd. at its sole discretion, may require a security deposit equal to an estimate of up to three (3) months projected prescription drug charges before reinstatement occurs.

OPTIONAL SERVICES AND FEES:

• Member Submitted Paper Claims - $ 2.50/transaction

• ID Card and Member Communication home delivery - $1.00 plus postage per address label. (SCL may modify this fee if due to changes in postage without advance notice)

• Claims Data Files - SCL shall provide electronic data files, upon request by the Sponsor, in an SCL approved file layout. Files will be

available to one (1) recipient at no additional cost for the term of the contract. Additional recipients - $150 setup fee / $100 charge per file

• Custom Data Reporting - Hourly rate determined by SCL based on the scope of the project

• Clinical Prior Authorization - $40.00 per review/appeal

• Letter of Medical Necessity Administrative Prior Authorization - $6.00

• Disease Management - $3.50 PEPM

• First Alert DM Notification - $0.50 PEPM

• Step-Therapy - $0.20 per paid transaction

• Specialized Data Integration (HDHP, HSA, etc) - $1.00 per paid transaction

Signature:

By signing in the space provided below, the authorized representative of the Client requests Script Care, Ltd. to establish a self-funded prescription drug program and acknowledges that until the Managed Prescription Drug Program Agreement is executed by the parties, this worksheet will be the sole document used to determine pharmacy benefit plan parameters for covered members and agrees to the payment procedures outlined above. By signing this worksheet, the Client stipulates and agrees that this worksheet constitutes a binding contract between the parties and that Client shall be bound by all of the terms hereof. Once the Client and Script Care, Ltd. have executed the Managed Prescription Drug Program Agreement, Client shall continue to be bound by the terms hereof to the extent that such terms do not conflict with the Managed Prescription Drug Program Agreement.

| | | |

Client Name Authorized Representative Signature

| |

Date

| | | |

TPA Name (Please Print Name and Title)

Changes made to this Worksheet after the Client approval has been received may delay the on-line claims processing effective date and/or the first checkwrite. In addition, if special programming is necessary in order for Script Care, Ltd. to process claims with the newly requested changes, it may not be possible to have them in place as of the scheduled effective date. The Agreement between Script Care, Ltd., and the Client will be provided for signature within ten (10) working days of receipt of this document. This document will serve as an interim contract with the following provisions in place until a fully executed contract has been received by Script Care, Ltd. Pharmacy benefit management services may be suspended if deemed necessary, pricing guarantees will not be honored until a fully executed contract has been signed and the Client will forfeit and not be eligible to receive rebates until a fully executed contract has been signed and received.

Submit the completed and signed PBW to your Account Manager and mail original to: Script Care, Ltd, 6380 Folsom Dr, Beaumont, TX 77706

INSTRUCTIONS FOR MAILING CARDS AND CONTRACTS:

Mail Initial Cards to: X TPA Group Participant’s Home (Fee Applies)

(addresses are required in PharmScreens)

Mail Daily Cards to: X TPA Group Participant’s Home (Fee Applies)

(addresses are required in PharmScreens)

Mail Contracts to: TPA X Group Other (Provide Mailing Address)

Note: Signed contracts must be returned within 15 days of effective date to avoid termination.

Revised 08/01/2014

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