CM-09-03-037Client Benefit Plan Design (BPD)
Application For Prescription
Program Services
WMS Client Application
WELCOME TO WMS!
This document contains the details of the prescription benefit plan design used to set up plan designs in
our system. Place an "X" in the box to indicate your selection. Gray shaded boxes are WMS'
recommended setup. If there are exceptions or notes that you wish to make, please include them in the
`Comments' section. THIS APPLICATION MUST BE COMPLETE BEFORE ANY PROGRAM
SET-UP CAN BEGIN. If you have questions, please contact your WMS Implementation Manager or
sales representative.
PLAN ID:
1. CLIENT ADMINISTRATION INFORMATION:
T PAICons u ltant/B ro ker:
Contact:
Address:
Phone:
Fax:
Email:
Plan Name:
Contact:
Address:
Phone:
Fax:
Email:
City of Round Rock
Linda Gunther
:MANN NVld
spot' punoN Jo A !C
221 East Main Street
Round Rock, Texas 78664
GENERAL INFORMATION
Effective Date: 2/1/2009
Business Type:
Est # Employees: 750
Est # Lives: 1500
Previous Vendor.
512-.218-.5490
512-218-5493
LOG AND DATE ALL CHANGES BELOW, MOST RECENT LISTED FIRST:
CM• 09.03 • D31
WMS Client Application
WHO IS YOUR CURRENT PROCESSOR? Aetna
CARD PRODUCTION PARAMETERS:
Cards Produced By: ❑ TPA ® WMS ❑ Fee ❑ Paper ❑ Hard
Card Delivery: Initial ❑ TPA ® Employer
Replacement ❑ TPA ® Employer
Special Instructions: (logo, etc...)
'Ship To' Address (If different from above):
Phone:
SEND INVOICE TO:
❑ TPA ® PLAN
ELIGIBILITY:
Will Eligibility be Provided to: ❑ FTP
Will Eligibility be Provided by: ❑ TPA
Will Group Update Eligibility Remotely? ❑ YES
Member ID numbers: ❑ SS #'s
2. PLAN ADMINISTRATION INFORMATION:
® WMS(wmselig@wal-mart.com)
® Plan
® NO
® Alternate ID #'s
STANDARD PROGRAM REQUIREMENTS (please 'X' one option - recommended set-up is shaded):
Program Type: ® Retail and Mail ❑ Retail Only ❑ Mail Only
Days Supply: (select the appropriate option)
RETAIL PROGRAM MAIL PROGRAM
® 90 Days Supply
❑ Units
❑ Days Supply or Units, whichever is GREATER
❑ Days Supply or Units, whichever is LESS
® 90 Days Supply
Units
Days Supply or Units, whichever is GREATER
Days Supply or Units, whichever is LESS
Refill: (select the appropriate option)
❑ Limit to two (2) - New plus one Refill - at Retail
Dependent Age Limits:
Rev. 07/2004
® No Limitations ❑ Other _
D at birth date Non Students N/A
0 end of month Students N/A
2
WMS Client Application
Max Dollar Paid per Claim:
Retail: ® $1,000 or ❑ Other
3. COPAY INFORMATION:
Retail Program: Generic $0.00
%
Mail: ® $3,000 or ❑ Other:
Brand(Preferred) $N/A Brand(Non-Preferred) $N/A
%
Please complete when a percentage is to be combined with a whole dollar copay.
❑ Additional Copay Amount ❑ Whichever is greater ❑ Whichever is lower
Mail Program: Generic $ 0.00
%
Brand(Preferred) $ N/A Brand(Non-Preferred) $N/A
OTHER OPTIONS SELECTED:
Coverage for Generic Drugs Only. Brand Drugs Excluded.
Note: Copay values that are established on the Plan may be overridden by a Maintenance Copay, a Pharmacy Network, Non -Formulary Copay, Formulary Special Rule, Plan Special Rule, Member
Copay, or Member Special Rule (in that order). Separate Copays can be set for Acute & Maintenance drugs and Compounds at the Plan level and/ or Pharmacy Network level. PERCENTAGE
COPAYS are always based on the total price of the claim that does not include Product Selection Penalty, Front End Deductible, or any amount exceeding the Maximum Benefit.
4. REPORTING:
Quarterly Claim Source by Drug Type ® Yes ❑ No
Prescription Count by Retail, Mail and Member Submit. Included features are Ingredient Cost, Dispensing Fee,
Member Contribution, Plan Cost and Formulary percentages.
**Other Reports available upon Request
5. DAW COMPONENT:
WMS offers several aggressive generic drug dispensing programs for groups interested in optimizing their saving
opportunities.
If a Brand drug has a specific equivalent Generic drug available and the member or doctor chooses the Brand, then the
member must pay the difference between the ingredient cost of the Brand drug and the Generic drug, plus a copay (can be
Brand or Generic, depending on how the group wants it priced).
If a Brand drug does not have a Generic equivalent, then the Brand copay applies.
Do you want to utilize Generic Differentials? (DAW Component) ❑YES ® NO
If YES, please indicate copay base: ❑ BRAND ❑ GENERIC
What percentage should the member pay when Doctor or patient refuses Generic? (Penalize on both DAW I and DAW II)
❑ ZERO ❑ 100% Other
What percentage should the member pay when Patient refuses Generic? (Penalize on DAW II only)
❑ ZERO ❑ 100% Other
Rev. 07/2004
3
WMS Client Application
6. DRUG COVERAGE:
ALL GENERIC FEDERAL LEGEND DRUGS ARE COVERED WITH THE EXCEPTION OF THE FOLLOWING BELOW
(Please X' one):
INCL= Include;EXCL=Exclude; P/A= Prior Authorization; S/T= Step Therapy Protocol, N/A=Not applicable
DRUG CATEGORY
INCL EXCL
P/A
S/T
Days supply, Quantity, Sex and Age Limits
1
ABORTIFACIENT
Mifetrex
X
2
AIDS
X
3
ANTI -FUNGALS, ORAL
X
4
ATTENTION DEFICIT DISORDER DRUGS
X
5
COMPOUNDED DRUGS
X
6
CONTRACEPTIVES
Oral
X
De so -Provera
X
Diaphragm
Nuvarin.
X
Emergency Contraceptives
Plan B, Prevent
X
Transdermal
X
7
COSMETIC AGENTS
Renova
X
Rooaine, Pro.ecia
X
8
DESIDRUGS
9
DIABETES
Insulin
X
Blood Glucose Monitors
X
Blood Su•arTestin. Su lies
X
S rin.es/Needles insulin onl
X
10
DIAGNOSTIC AGENTS
X
11
DME Crutches, Walkers, Bandases
X
12
FERTILITY non-in'ectable
X
13
FLUORIDE PREPS & WASHES
X
14
IMPOTENCY
DRUGS
Via.ra, Cialis, Levitra
X
Caverject, Edex, MUSE
X
MIGRAINE
MEDICATIONS
Amer.e
X
Frova
X
Imitrex tablets
X
Imitrex S.ra Inhaler
X
Imitrex S rin.es
X
Imitrex Vials
X
Maxalt/Maxalt MLT
X
Relax
X
Zomi./ Zomi. ZMT 2.5 m.
X
Zomi./Zomi. ZMT 5 m.
X
Zomi. Nasal S.ra
X
4
Rev. 07/2004
WMS Client Application
DRUG CATEGORY
INCL
EXCL
PIA
SIT
Days supply, Quantity, Sex and Age
Limits
16
OSTOMY SUPPLIES
X
17
OVER THE COUNTER (OTC)
Bronchosaline, Codeine-containing preparations
X
Prilosec OTC and its generic OTC versions
X
Claritin OTC, Claritin-D, Claritin syrup and generic OTC versions
X
18
PRESCRIPTION STRENGTH MULTIVITAMINS
Vitamin B-12
X
Pediatric Fluoride Vitamins
X
Prescription Prenatal Vitamins
X
19
PRESCRIPTION STRENGTH NON-SEDATING ANTIHISTAMINE
X
20
PRESCRIPTION STRENGTH PROTON PUMP INHIBITORS
X
21
SERUMS / TOXOIDS/ VACCINES / ALLERGENS
X
22
SMOKING DETERRENTS
Nicotine (prescription strength)
X
Zyban
X
23
TOPICAL AGENTS
Elidel
X
Protopic
X
Retin A, Avita, Differin
X
Tazorac
X
24
WEIGHT LOSS MEDICATIONS
25
OTHER SPECIFIC COVERAGES
Celebrex, Bextra
X
Stadol Nasal Spray
X
Singulair
X
Accolate
X
26
INJECTABLES
Chemotherapy
X
Epipen, Anakit
X
Glucagon
X
Hematinics
X
27
SPECIALTY DRUGS
Avonex, Copaxone, Betaseron, Rebif
X
Arava, Enbrel, Humira, Kineret, Remicade, Hyalgan,
X
Epogen, Procrit, Aranesp
X
Neupogen, Neulasta, Neumega
X
Fertility (injectable)
X
Growth Hormones
X
Immune Globulins
X
Anti-Hemophilic Factors
X
Forteo
X
Botox
X
Copegus,Roferon, Intron-A, Infergen, Hepsera, Pegasys,
Peg-Intron, Rebetron
X
Lupron
X
Pulmozyme, TOBI
X
Synagis
X
Xolair
X
Provigil, Xyrem
X
Zelnorm, Lotronex
X
Raptiva, Amevive
X
Zyvox
X
Tracleer, Flolan
X
Rev. 07/2004
5
WMS Client Application
SPECIALTY PHARMACY PROGRAM:
WMS offers a Specialty Pharmacy Program integrated with a comprehensive Specialty Pharmacy Network for the
distribution and management of costly specialty pharmaceuticals. This initiative is complemented with a clinical support
program that involves prior authorizations and protocols designed to enhance patient's healthcare as well as to manage costs
incurred by health plans to offer these therapies.
❑ YES (Mail Specialty Contract) ® NO
Other Program Variations: (identify specific drug coverage differentiations between the Retail and Mail Service programs)
COVERAGE FOR GENERIC DRUGS ONLY. BRAND DRUGS EXCLUDED.
7. PROGRAM CONTROL DESIGN PRICING
PLAN MODEL: ❑ Pass Through ® Traditional
RATES:
• RETAIL: Wal-Mart Pharmacies - Generic = AWP -54% + $1.99 Dispensing Fee
• MAIL: Generic = AWP -50% + $1.99 Dispensing Fee
• SPECIALTY N/A
ADMIN FEE: $.50
PAPER CLAIM (DMR) FEE: $N/A
REBATES: N/A
Pharmacy Networks: Pharmacy access is provided to all members for dispensing prescriptions. Select the appropriate
network option from those below (note: Restricted & Custom networks require WMS management approval).
►1
Rev. 07/2004
Open — National Pharmacy Network which includes over 55,000 pharmacies.
Wal-Mart Pharmacy Only
Custom - Specific participating WMS pharmacies and/or service areas may be accessed.
NABP # Store # City, State
NABP # Store # City, State
NABP # Store # City, State
NABP # Store # City, State
6
WMS Client Application
Plan Accumulators: Limits may be placed on the amount of benefits a member may receive, or on the amount the member
is responsible for. Limits may also be placed on each family member individually, or on the family as a whole. The three
types of accumulators available are defined as follows:
A. Deductible: An amount the beneficiary must pay before plan payment of covered services begin.
❑ Plan Year ❑ Calendar Year
❑ Individual $ ❑ Family $ N/A
B. Out of Pocket: A limit on total member copays, deductibles, and coinsurance under a benefit contract.
❑ Plan Year ❑ Calendar Year
❑ Individual $ ❑ Family $ N/A
C. Maximum Annual Benefit: A limit on the amount of reimbursed services for a given year.
❑ Plan Year ❑ Calendar Year
❑ Individual $ ❑ Family $ N/A
Combination of Accumulation: If accumulators are used on a plan with both a Retail and Mail plan, the accumulators may
be calculated together or separately. Select the appropriate combination of accumulation:
❑ Retail plus Mail Together
❑ Retail Only ❑ Mail Only
❑ Exclude Generics
Accumulation Period: Accumulators can be accrued for any period of time, after which point they are reset. Select the
appropriate period of accumulation:
Period: ❑ Calendar Year ❑ Fiscal Year (ending
Duration: Months Date: to
Exceed Accumulation Options: If accumulators are used on a plan, specific parameters can be set to determine how
prescriptions should be processed once the member meets the maximum benefit.
❑ B — Process only WITH percentage from Extra Copay%
❑ R — Reject The Claim
❑ G — Generic Incentives. Generics Covered. 100% Copay On All Others
❑ M — Mandatory Generics. Generics Covered. Reject All Others
❑ C — Process all claims with set Percentage Copay
❑ P — Process All Types of Drugs with 100% Co -Pay
Annual and Lifetime Maximums: Annual or lifetime dollar limits may be placed on the drugs in the table below. These
items are generally classified as not medically necessary. If you do cover these items, it is recommended that the amount of
coverage be limited, especially for smoking cessation and fertility, which are treatments that often times need to be repeated.
ANNUAL
LIFETIME
Fertility:
$
$
Smoking:
$
$
Growth Hormone:
$
$
Rev. 07/2004
7
WMS Client Application
I hereby declare that I have read and fully understand all statements and questions on this application, and that the responses
shown on this application are complete and true to the best of my knowledge and belief, and fully represent my intentions. I
hereby authorize WMS to implement this setup according to the parameters outlined in this document. Any changes to the
above information will be submitted to WMS in writing, indicating the effective date of the change.
Telt Approval:
Client Approval:
Title
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°Company Name
Date
Rev. 07/2004
8
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BLUE SHEET FORMAT
DATE: March 6, 2009
SUBJECT: City Manager Approval -March 13, 2009
ITEM: Application for the Wal-Mart Agreement approved by council on
01/08/2009.
Department: Human Resource Department
Staff Person:
Justification:
Funding:
Cost:
Teresa Bledsoe
Wal-Mart Client Application for generic prescription program
services.
General Fund, Water / Waster Utility Fund
The cost of this insurance is a function of the number
of employees and dependent units covered.
Source of funds: City contribution and employee paid premiums for
dependent health care.
Outside Resources: N/A
Background Information:
Public Comment:
Blue Sheet Format
Updated 01/20/04