2022/08/31 Council Agenda Packet

(c) CorVel's PBM will present a proprietary or state mandated Formulary to Customer. Upon presentation of identification to a Participating Pharmacy, the Formulary will trigger the Participating Pharmacy's adjudication system to either: i. Automatically dispense certain medications, or Obtain Prior Authorization (PA) approval from claims professional to dispense, (d) CorVel's PBM will implement a Concurrent Drug Utilization Review ("DUR") program on behalf of Customer,. Concurrent DUR includes a review of the drug history at the time the prescription is presented. Absent Customer's directions, DUR shall be performed in accordance with CorVel's PBM's standard service model. W. BILLING AND PAYMENTS OF PHARMACY PROGRAM. (i) Financial obligations of parties. (i) Customer shall be financially responsible for all drug charges incurred by claimants for dispensed medications processed under CorVel's PBM. CorVel assumes no liability for drug charges with the exceptions noted below in subsection iii. (ii) If the CorVel claims professional determines, upon receipt of CorVel's PBM invoice, that specific formulary and non -formulary drugs should not have been dispensed, the CorVel claims professional should inform the PBM as soon as possible. 1. The PBM will request a reversal from the Participating Pharmacy. If granted, CorVel will reverse the drug charges, however, if the Pharmacy does not grant the PBM's request, Customer is responsible for payment of the drug charges; CorVel assumes no liability for drug charges with the exceptions noted below in subsection iii. (iii) Upon receipt of an invoice, CorVel claims professional may timely dispute charges for drugs that were dispensed in error, triggering CorVel's PBM to reverse the drug charges, by notifying CorVel for any of the following reasons: 1. CorVel's PBM and/or the Participating Pharmacy's violation of Formulary or Utilization Review Parameters set forth in Customer's DUR program, or in the Claimant Level Formulary; or 2. Duplicate or inadvertent entries or other clerical mistakes on a PBM invoice. (ii) Invoicing and Payment. On a per Covered Drug basis CorVel will apply daily for all drug charges and fees related to the PBM directly to the claim file. CorVel shall invoice and bill directly all prescription fees to the specific claims file. CorVel uses Medi-Span as our AWP data source. CorVel's Medi-Span database is updated daily and AWP values are applied on the date of dispense. In all states with the exception of California, Customer will be billed the lessor of the state fee schedule AWP or the CorVel's negotiated rate. City of Everett, WA — CorVel EC Amendment 3 7-25-2022