This Appendix defines an overview of the RX Insights Services specified in the Order Form between Client and Benefitfocus. Detail regarding specific tasks, resources, and deliverables are defined within the project plan created as part of project coordination and discovery.
I. RX Insights Implementation Services:
A. Implementation Services
1. Project coordination and discovery services:
a. Review project timeline
b. Collect applicable prescription data
c. Provide overview of RX Insights Services
d. Hold regular status calls
B. Project Dependencies and Timeline:
1. Prior to the initial launch meeting of Client, Client is required to provide to Benefitfocus and RazorMetrics the following data:
a. Test the facilities for using Client’s existing PBM data file source(s) for RX Insights.
i. A minimum of 12 months of historical, identified claims data. The claims must contain the necessary fields required by the Benefitfocus claims analysis process as defined in the “RazorMetrics Data Specification”.
ii. Eligibility data for Employees and Members in the Member Group which identifies the employment status of each Employee, the plan in which the employee is enrolled and current dependent information.
b. Current Program Formulary (preferably in electronically readable format).
i. Formulary updates are to be provided within 30 days of changes.
ii. Information on any medications which should be excluded in the switching process or given preferential treatment in the selection of alternatives (e.g., rebate eligible drugs)
c. Any Client specific logo and health plan name to be used on the fax to be delivered to Prescribers. If none are provided, the RazorRxAssistant logo will be used, and the health plan name will be: ‘<CLIENT NAME> Health Plan’
d. Updates to the data identified in the preceding section will be provided as available with the provision that claims and enrollment data will be updated no less than monthly. The Client will ensure that updated data conforms to the standard requirements and format required by Benefitfocus.
2. Requested onboarding and go-live dates.
3. First switches to prescribers identified in Client claims will typically occur within 90 calendar days of receipt and approval of the data specified in this Section.
4. RX Insights training that explains savings and provides visibility on progress.
II. Summary of RX Insights Software and Ongoing Services:
A. Benefitfocus will provide access to the RX Insights reports within the Health Insights platform to evaluate drug spend through analysis of historical pharmacy claims and leverages an automated, scalable workflow to effectuate the switch from higher cost to lower cost medications through engagement with prescribers and pharmacies.
B. Client will provide necessary pharmacy claims, formulary, rebate structure and eligibility data to analyze each claim through the Intervention Codex rules engine. This process will identify Member medications which may be eligible for a lower cost drug alternative, (referred to as switches). Proposed switches may include brand-to-generic, brand-to-lower-cost brand or numerous other cost optimized drug switches.
C. At intervals of not less than monthly, Benefitfocus will receive updated pharmacy claims data and enrollment from the Client and will process that information in accordance with the service requirements subject to Benefitfocus standards. Changes in formulary, benefit plan or rebate information will be provided to Benefitfocus within 30 days of their availability to Client.
D. Benefitfocus will produce and make available the necessary activity detail, management reporting and results of the program to the Client in the form of data and reports, as it applies to the Client. Provided data (a daily, incremental feed of events) will identify key states in the workflow (e.g., switch delivered to prescriber, prescriber response received, prescriber acceptance) for each identified medication switch for Client.
E. Benefitfocus will provide first line support to Client.
F. As per the Client, all Client Members are included (‘opted in’) to the program by default. The Client may provide a list of Members (by Member Group Member_ID) who wish to opt out of the program. ‘Member Opt Out’ requests submitted by the Client will be processed within 30 days of receipt. Alternative options for Member Opt Out may be available to the Member (i.e. application, website or email). Once a Member has opted out, subsequent pharmacy claims for that Member will not be analyzed or processed.